Failure to Maintain Infection Control and Employee TB Screening
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by multiple instances where staff did not adhere to established protocols for Enhanced Barrier Precautions (EBP) and general infection control. Staff were observed failing to change gloves, perform hand hygiene, and wear gowns during high-contact care activities for residents on EBP, including those with multidrug-resistant organisms, wounds, catheters, and feeding tubes. In several cases, staff placed soiled gloves and linens directly on the floor rather than in designated bags, and did not consistently use required personal protective equipment (PPE) such as gowns during resident transfers, wound care, and hygiene assistance. Specific observations included a certified nurse aide providing peri care and handling soiled briefs without wearing a gown and placing contaminated items on the floor. A nurse was seen changing wound dressings and handling linens without a gown, and also placed dirty linens on the floor. In another instance, both a nurse and a CNA transferred a resident using a mechanical lift without donning gowns, and staff were observed touching multiple surfaces and resident care items with the same pair of gloves, including after contact with urinary catheters and resident faces. Additionally, a blood glucose testing machine was used on multiple residents without proper disinfection between uses or placement of a barrier on the medication cart, contrary to facility expectations. The facility also failed to ensure that newly hired employees completed the required two-step Mantoux tuberculin skin test (TST) for latent tuberculosis infection. Review of employee records revealed missing documentation for both the dates and results of the first and second steps of the TST for the majority of sampled new hires. The infection control preventionist indicated that human resources was responsible for notifying nursing staff about TB testing needs, but records were incomplete or missing for nine out of ten sampled employees.