Infection Control Program Deficiencies and Lapses in Aseptic Technique
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by incomplete and inaccurate infection surveillance, improper storage and handling of medical equipment, and lapses in aseptic technique during care and medication administration. The infection surveillance system did not accurately capture or categorize infections, with many entries listed as "unknown" and lacking essential details such as signs, symptoms, and treatment measures. The Infection Preventionist was unable to identify specific infections for residents listed in the "other" category, and some residents with active infections were omitted from surveillance reports. The transition from paper to electronic records resulted in missing information, further compromising the surveillance process. Multiple residents experienced breaches in infection control practices. For example, one resident's gastrostomy tube tubing was observed in contact with urinary catheter tubing, and there was evidence of urine leakage and odor in the area. Another resident's nasal cannula oxygen tubing was repeatedly stored directly on a wheelchair seat or bed linens, without a respiratory storage bag, exposing it to potential contamination. Similarly, another resident's handheld nebulizer tubing and non-rebreather mask were not stored in a sanitary manner, being left on surfaces or in drawers with other items, and were used for medication administration without cleaning or disinfection. Staff interviews confirmed that these storage practices did not meet facility expectations for infection control. Additional deficiencies included improper aseptic technique during intravenous medication administration and wound care. A nurse was observed scrubbing a PICC line hub for only 3-4 seconds instead of the required 15 seconds, and the competency forms did not specify the correct duration. During wound care, a nurse failed to perform hand hygiene at critical points, such as after removing soiled gloves and before donning clean gloves, and touched soiled materials before proceeding to clean tasks. During medication administration, a nurse picked up a dropped pill with an ungloved hand and gave it to a resident, contrary to facility policy. Staff interviews confirmed awareness of proper procedures but acknowledged that they were not followed in these instances.