Widespread Infection Control Failures and Documentation Lapses
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by multiple deficiencies in surveillance, documentation, and adherence to infection control protocols. The infection surveillance system was incomplete and inaccurate, with missing documentation of signs and symptoms for the majority of residents listed on monthly infection reports from January to April. The Infection Preventionist and nursing staff did not consistently document or review laboratory results, including those for Group A Streptococcus surveillance, where 71 residents were swabbed but results were not reviewed or documented in the medical record as required. Staff did not consistently perform or assist residents with hand hygiene prior to meals in the dining area, despite facility policy and staff interviews confirming this as an expectation. Observations revealed that staff served drinks and meals to residents without ensuring hand hygiene was performed. Additionally, staff failed to use appropriate personal protective equipment (PPE) during high-contact care activities for residents on Enhanced Barrier Precautions and Contact Precautions. For example, a CNA did not wear a gown or gloves while assisting a resident with a wound on Enhanced Barrier Precautions, and a nurse entered a contact precaution room, adjusted linens, and performed a dressing change without proper PPE or hand hygiene. Further deficiencies included improper hand hygiene and glove use during medication administration, such as injections and nasal sprays, and during dressing changes. Clean dressing supplies were placed directly on unclean surfaces without a barrier, and shared resident equipment, such as blood pressure cuffs, was not disinfected between uses. Staff interviews confirmed a lack of awareness or failure to follow established infection control policies, contributing to the observed lapses in infection prevention practices.