Deficient Infection Surveillance and Improper Wound Care Practices
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by incomplete and inaccurate infection surveillance and improper wound care practices. Review of the facility's infection surveillance policy and line listings for several months revealed that documentation of signs and symptoms of illness was frequently missing, and culture results identifying organisms for urinary tract infections were often not included. Additionally, a significant laboratory finding of ESBL in a resident's urine culture was not recorded on the facility's infection line listing. Interviews with the Infection Control Nurse and Regional Nurse confirmed that culture results, lab reviews, and symptoms were not consistently documented on the infection tracker or line listing, contrary to facility policy and infection surveillance standards. A specific incident involving a resident with dementia and unstageable pressure ulcers highlighted further deficiencies in infection control practices. During a wound dressing change, a nurse failed to perform hand hygiene or change gloves between removing old dressings and cleansing wounds on both feet. The nurse also re-applied a dressing that had fallen onto a towel and bed linens, rather than using a new, clean dressing. These actions were observed directly by a surveyor and later acknowledged by the nurse and the Director of Nursing as not meeting the facility's wound care protocol, which requires hand hygiene and glove changes after removing old dressings and prohibits re-applying contaminated dressings. The combination of incomplete infection surveillance documentation and improper wound care procedures demonstrates the facility's failure to provide a safe and sanitary environment to prevent the development and transmission of communicable diseases and infections. These deficiencies were confirmed through record review, staff interviews, and direct observation.