Failure to Implement Comprehensive Infection Control Program
Penalty
Summary
The facility failed to implement and operationalize a comprehensive infection prevention and control program, as evidenced by multiple observations and interviews. Surveyors observed that hand hygiene practices were not followed by staff, including dietary and nursing assistants, who did not use hand sanitizer or wash hands before leaving residents' rooms after delivering food or providing care. Hand sanitizer dispensers were missing from some resident rooms, and staff were seen touching contaminated surfaces and moving between residents without performing hand hygiene. Additionally, soiled room divider curtains and lack of accessible hand hygiene equipment were noted. The infection control (IC) program lacked accurate and complete outcome and process surveillance. The IC nurse was unfamiliar with the facility's surveillance processes, could not explain discrepancies in infection data, and was unaware of the water management plan. Infection surveillance documentation was incomplete, with missing summaries and analyses, inconsistent line listings, and lack of documentation for some infections. For example, a resident with a wound culture positive for infection was not included on the line list and did not receive documented treatment. Another resident's infection was listed twice with conflicting information, and there was no documentation of whether infections met McGeer criteria. Covid-19 cases were not consistently tracked or reported, and there was no evidence of health department notification or outbreak investigation. The facility also failed to respond appropriately to a staff report of potential bed bugs. When aides reported possible bed bugs in a resident's bedding, the maintenance director, who lacked clinical credentials, conducted a skin assessment instead of nursing staff. No nursing skin assessment or follow-up documentation was found in the resident's medical record. The pest control company was called and then canceled by the maintenance director without proper investigation or documentation. Staff were not informed of the incident during shift reports, and there was no clear policy or procedure for handling such situations. Overall, the facility's infection control program was disorganized, with inadequate documentation, lack of staff education, and insufficient monitoring of both residents and staff for infections.