Failure to Implement Infection Prevention and Control Program
Penalty
Summary
The facility failed to implement its infection prevention and control program as evidenced by multiple observations of staff not adhering to Enhanced Barrier Precautions (EBP) and proper infection control practices. In one instance, two certified nurse aides provided a bed bath to a resident with a feeding tube and severe cognitive impairment without wearing the required gowns, despite clear signage indicating EBP was necessary. The aides also failed to change gloves between soiled and clean activities, left the room with soiled gloves without performing hand hygiene, and continued care after inadequate handwashing. Both aides acknowledged awareness of the EBP requirements but admitted to not following them during care. Another resident, who was cognitively intact but nonverbal and dependent on staff for care, was observed receiving morning care from a certified nursing assistant who did not use any PPE, despite signage indicating EBP was required. The assistant used the same gloves and washcloths for both clean and soiled areas, mixed clean and dirty linens, and failed to perform hand hygiene when leaving and re-entering the room. A registered nurse assisted in transferring the resident but did not ensure the assistant donned appropriate PPE, even though the nurse was aware of the requirements and the assistant's noncompliance. Additionally, the facility's infection surveillance system was found lacking in tracking and documenting staff illnesses. The call-in log for staff absences due to illness did not consistently record essential information such as the unit worked, specific symptoms, onset dates, or return-to-work dates. The infection control preventionist confirmed these gaps, and there was no documentation of follow-up or analysis to identify potential clusters or prevent the spread of infection, contrary to facility policy and procedures.