Failure to Implement and Maintain Infection Prevention and Control Program
Penalty
Summary
The facility failed to implement and maintain an effective infection prevention and control program, as evidenced by multiple deficiencies observed during the survey. For one resident with a right hip surgical incision and a PICC line, there was no Enhanced Barrier Precautions (EBP) signage or Personal Protective Equipment (PPE) cart available prior to room entry on several occasions. Additionally, a nurse was observed hanging an IV line while wearing only gloves and no other PPE. The Director of Nurses confirmed that EBP signage and PPE should have been present due to the resident's wounds and medical devices, but these measures were not in place. Another resident with severe cognitive impairment and multiple unhealed pressure ulcers was not provided with EBP during wound care. During a wound dressing observation, nurses failed to don gowns and did not perform hand hygiene between glove changes, despite handling open wounds. The nurse involved acknowledged that residents with wounds should be on EBP and that she should have worn a gown and performed hand hygiene, but these protocols were not followed. The Director of Nurses, acting as the Infection Preventionist, also stated that EBP should have been implemented for residents with wounds and that staff should wear gowns and gloves during wound care. The facility also lacked a documented infection control surveillance plan for identifying, tracking, monitoring, and reporting infections, communicable diseases, and outbreaks among residents and staff. The Director of Nurses admitted there was no active Infection Preventionist, no line listings, and no data available regarding infection rates or surveillance. Furthermore, the facility did not have a documented water management program to address the risk of Legionella and other waterborne pathogens, and key staff were unaware of the required assessments and control measures. These failures were confirmed through interviews with facility leadership, who acknowledged the absence of required infection control documentation and oversight.