Widespread Infection Control Failures and Lapses in Precaution Implementation
Penalty
Summary
Facility staff failed to follow infection control practices and guidelines, resulting in multiple deficiencies related to the prevention and transmission of infection and disease. Observations revealed unsanitary conditions, such as unlabeled and improperly stored basins, urinals, and urine collection hats in resident rooms and bathrooms, as well as soiled gloves and washcloths left in inappropriate places. Mold-like substances were observed in several areas, including shower rooms, the activity room office, and the HR office, with staff confirming awareness of these issues. The facility's own policy required single-resident use and proper storage of bedpans and urinals, which was not followed. During medication administration to a resident with a gastrostomy tube and foley catheter, staff failed to don appropriate PPE and did not post Enhanced Barrier Precautions (EBP) signage as required. Although records indicated an order for EBP and an updated care plan, these precautions were not implemented at the time of observation. Interviews with staff and the DON confirmed that PPE should have been used and signage should have been present for residents with such medical devices. The facility also failed to ensure that residents with infectious diseases or those requiring EBP had appropriate physician orders, care plans, and signage. For example, a resident with a history of sepsis and multiple infections did not have an order or care plan for contact precautions, and staff were unclear about the reason for precautions. Additionally, several residents identified as EBP candidates did not have the required orders or signage on their doors, and staff confirmed these omissions during interviews. These failures were evident across multiple hallways and affected several residents reviewed during the survey.