Failure to Implement and Maintain Infection Prevention and Control Program
Penalty
Summary
The facility failed to implement and maintain an effective infection prevention and control program as required by policy and physician orders. In one instance, a resident with a peripherally inserted central catheter (PICC) line was observed receiving an intravenous medication infusion from an LPN who did not wear a gown, despite the presence of an Enhanced Barrier Precaution (EBP) sign and caddy with gowns and gloves at the resident's door. The facility's policy and posted instructions required staff to wear both gown and gloves during high-contact care activities involving central lines. The LPN confirmed awareness of the EBP signage but stated she did not believe a gown was necessary during the procedure. In another instance, a CNA providing incontinence care to a resident with neuromuscular dysfunction of the bladder failed to change gloves and perform hand hygiene after removing a soiled brief and before applying skin barrier cream and a clean brief. The CNA disposed of the soiled brief, cleaned the resident, and then, without changing gloves or performing hand hygiene, applied barrier cream and a clean brief. The CNA later confirmed the expected process was to change gloves and perform hand hygiene before these steps. The Director of Nursing also confirmed the expectation for staff to follow proper glove and hand hygiene protocols during such care.