Failure to Maintain Infection Control Practices for Central Line Care and Mask Use
Penalty
Summary
The facility failed to maintain appropriate infection control practices for one resident and one unit, potentially affecting multiple residents. One resident, who had a history of left knee prosthesis infection and a peripherally inserted central catheter (PICC) line, was sent to the hospital after it was discovered that their PICC line had been left uncapped overnight. The resident reported that the night nurse left the line uncapped for approximately ten hours, which was confirmed by the hospital's emergency department report. The facility's documentation did not include the reason for the resident's transfer, and the only available explanation was found in the hospital's records, which were not part of the resident's medical record at the facility. Additionally, on the Blue Neighborhood unit, staff failed to adhere to required mask protocols during a period when a resident with COVID-19 was present. Observations showed a certified nursing assistant repeatedly wearing a surgical mask below the nose and a housekeeper not wearing any mask, despite posted signage and facility policy requiring surgical masks for all staff on the unit. The Director of Nursing confirmed that all staff were expected to wear masks on the unit due to the presence of a COVID-positive resident. These deficiencies were observed through interviews, record reviews, and direct observation, and were corroborated by reference to CDC guidelines and facility policies regarding infection prevention and control, including the proper use of personal protective equipment and the care of central lines.