Failure to Maintain Infection Control Program and Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, as evidenced by improper disinfection of shared resident medical equipment and non-adherence to infection control guidelines during medication administration. Specifically, a nurse was observed using a glucometer on multiple residents without proper cleaning and disinfection between uses. The nurse placed the glucometer and related supplies in a container that was set on uncleaned surfaces in resident rooms, and did not use the manufacturer-recommended bleach wipes or follow the required contact time for disinfection. Instead, alcohol hand wipes were used, and the nurse was unaware of the correct procedures for cleaning the glucometer and the importance of not bringing contaminated equipment into resident rooms. Interviews with staff revealed inconsistent knowledge and application of infection control policies, including the use of appropriate disinfectants and adherence to contact times. Additionally, the facility failed to implement Enhanced Barrier Precautions (EBP) for a resident with a stage 3 pressure ulcer. The resident, who had intact cognition and was admitted with multiple diagnoses including a pressure wound, did not have EBP signage on the room door, and the care plan and physician orders did not indicate the use of EBP. During a wound dressing change, the nurse wore gloves but did not don a gown, contrary to facility policy and CDC guidelines for residents with wounds. Staff interviews revealed confusion regarding the criteria for EBP, with some staff believing it was only necessary for infected wounds, while facility policy and the DON stated that EBP should be used for any resident with wounds or indwelling devices. The findings were based on direct observation, staff interviews, and review of facility policies, manufacturer guidelines, and resident records. The lack of adherence to established infection control protocols and inconsistent staff knowledge contributed to the deficiencies identified in the infection prevention and control program.