Failure to Implement Infection Control Program and Enhanced Barrier Precautions
Penalty
Summary
The facility failed to implement and maintain an effective infection prevention and control program, as evidenced by multiple observations and interviews. Specifically, the facility did not ensure the use of Enhanced Barrier Precautions for a resident with a percutaneous endoscopic gastrostomy (PEG) tube. The facility's policy required gowns and gloves to be available and used during high-contact care activities, such as tube feeding. However, during several observations, there was no enhanced barrier precaution signage on the resident's doorway, and gowns were not accessible outside the room. A nurse was observed providing tube feeding care to the resident while only wearing gloves and not a gown, contrary to facility policy. The nurse stated she did not wear a gown because there was no signage indicating the need for enhanced precautions. The resident involved had a history of muscle wasting, depression, and dysphagia, and required substantial assistance with oral hygiene and tube feeding therapy. The care plan indicated the need for enhanced barrier precautions during tube feeding, but these were not followed during the survey period. The DON confirmed that staff should be wearing gowns during tube feeding care and that enhanced barrier precautions were expected but not implemented in this case. Additionally, the facility lacked a system for appropriate infection surveillance. The DON and Assistant DON both reported that no infection line listings or logs were being maintained, and there was no documentation to show infection tracking or trending. The Assistant DON had not received training on the infection control program, and the DON was unable to provide any evidence of infection surveillance activities. Furthermore, the facility's water management program was incomplete, lacking an assessment or mapping to identify potential sources of waterborne pathogens such as Legionella.