Failure to Maintain Infection Control Precautions and Annual Policy Review
Penalty
Summary
The facility failed to maintain proper infection prevention and control practices in two key areas. During observation rounds, an Enhanced Barrier Precautions sign was posted on the door of a resident room, but there was no indication as to which resident within the shared room the precautions applied to. When interviewed, a GNA staff member was unable to identify which resident required the enhanced barrier precautions. Review of medical records revealed that a resident in the room had a facility-acquired stage IV pressure ulcer requiring these precautions, but this information was not clearly communicated or identified for staff. Additionally, the facility did not conduct an annual review of its Infection Prevention and Control Program (IPCP), specifically the Antibiotic Stewardship policy. The policy was last revised in August 2018 and was due for review in August 2019. When asked for documentation of annual review, the administrator was unable to provide any evidence that the policy had been reviewed or updated since 2018, only noting that updating policies was an area needing attention.