Failure to Maintain Effective Infection Prevention and Control Practices
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, as evidenced by multiple observed breaches in infection control practices among staff caring for residents under Transmission-Based Precautions (TBP) and Enhanced Barrier Precautions (EBP). Direct care staff, including State Tested Nurse Aides (STNAs) and Licensed Practical Nurses (LPNs), were observed providing care to residents without donning required personal protective equipment (PPE) such as gowns and gloves, despite facility policy and CDC guidelines mandating their use during high-contact activities. In several instances, staff exited resident rooms wearing contaminated gloves, transported trash without removing gloves or performing hand hygiene, and failed to clean and disinfect shared equipment such as Hoyer lifts and portable vital sign machines after use. Interviews with staff revealed a lack of understanding and inconsistent knowledge regarding the facility's infection control policies, particularly concerning the requirements for PPE use under EBP. Some staff members were unable to explain the meaning of EBP or the specific circumstances under which gowns and gloves were required. Residents reported that staff routinely failed to wear gowns during direct care activities, including assistance with bedpans and wound care, even when PPE was available in the room. Additionally, observations showed that PPE was not always stored in a sanitary manner, with clean gowns found on the floor outside isolation rooms. Leadership interviews indicated that while staff received initial and ongoing training on infection prevention and control, there were no formal audits in place to monitor compliance. The Infection Preventionist and Director of Nursing acknowledged expectations for adherence to CDC guidelines and facility policy but were unable to account for the observed lapses in practice. The cumulative effect of these actions and inactions resulted in a failure to provide a safe, sanitary, and comfortable environment and did not prevent the development and transmission of communicable diseases and infections among residents.