Failure to Maintain Infection Control During GAS Outbreak and Wound Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program during a Group A streptococcal (GAS) outbreak. Staff did not consistently use appropriate personal protective equipment (PPE) when entering rooms of residents on transmission-based precautions for GAS. Multiple staff members, including a nurse, a CNA, and the Activities Director, entered rooms of GAS-positive residents without donning the required PPE, despite clear signage indicating the need for full PPE. Staff interviews revealed confusion about when PPE was required, and signage placement contributed to missed precautions. The facility's infection surveillance system was not accurately maintained. Review of monthly surveillance line listings showed that infections were recorded as healthcare-associated infections (HAIs) without sufficient documentation to meet the facility's pre-defined McGeer criteria. For example, some residents were listed as having HAIs for urinary tract or skin infections without the necessary symptoms or diagnostic evidence. The Director of Nursing acknowledged that the surveillance records were incomplete and did not meet the established criteria. Proper hand hygiene and glove use were not followed during wound care for a resident with dementia and bullous pemphigoid. During a dressing change, a nurse failed to change gloves or perform hand hygiene between care of different wounds, and an assisting nurse handled the resident without gloves. Both staff members later acknowledged that they did not follow infection control practices as required by facility policy and standard procedures. The Director of Nursing confirmed that hand hygiene and glove use expectations were not met during these care activities.