Failure to Implement Infection Control Precautions and Hand Hygiene
Penalty
Summary
The facility failed to implement its infection prevention and control program as required, resulting in several deficiencies. For two residents with physician orders and care plans indicating strict contact isolation due to ESBL urinary tract infections, there was no contact isolation signage posted on their doors as required by facility policy. This was confirmed by observation and by the Director of Nursing, who acknowledged the absence of the necessary signage for both residents. Additionally, a resident on Enhanced Barrier Precautions (EBP) due to an indwelling urinary catheter did not receive care in accordance with EBP policy. A CNA performed catheter and incontinence care without donning a gown, contrary to the facility's EBP policy, and was unaware that the resident was on barrier precautions. Furthermore, another CNA failed to perform hand hygiene or change gloves during incontinence care for the same resident, despite facility policy and CDC guidelines requiring hand hygiene between resident contact and after glove removal. Both CNAs confirmed their lapses during interviews.