Failure to Maintain Infection Prevention and Control Standards
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by multiple deficiencies observed during survey rounds and interviews. Surveyors found that Enhanced Barrier Precautions (EBP) signage was inconsistently applied and did not clearly identify which resident in double-occupancy rooms required precautions. In several cases, EBP signage was present without corresponding infection control supplies available for staff use, and staff were unable to identify which resident the precautions applied to. Medical record reviews revealed discrepancies, including signage for residents not on EBP and lack of clear identification for those who were. Staff interviews confirmed confusion regarding the identification system, with inconsistencies noted in the use of green dots to mark residents requiring EBP. Additionally, the facility failed to maintain proper infection prevention standards in the laundry area. Observations revealed that clean laundry was stored against stained, damp, and peeling cement walls, and directly beneath a large hole in the ceiling with protruding debris. These conditions were present in the room where clean laundry was processed, posing a risk for contamination. The facility administrator was made aware of these environmental concerns during the survey.