Failure to Implement Infection Control Practices and Documentation
Penalty
Summary
Staff failed to consistently implement appropriate infection prevention and control practices, particularly regarding the use of personal protective equipment (PPE) and hand hygiene. Multiple staff members did not don required gowns and gloves when providing high-contact care to residents on enhanced barrier precautions (EBP) for wounds or indwelling devices. For example, staff provided personal care, transferred residents, changed dressings, and handled soiled linens without wearing the necessary PPE or performing hand hygiene between glove changes. In some cases, staff were unaware of the current precaution status of residents or did not follow posted EBP signage, and one resident reported that staff did not use PPE during dressing changes for surgical wounds. Staff also failed to follow transmission-based precautions for residents on contact precautions. Observations revealed that staff entered rooms and provided direct care, such as repositioning and transferring, without donning gloves or gowns as required. In one instance, a resident with a contact precaution sign for pink eye reported that staff never wore PPE, and there was no PPE cart or appropriate disposal containers available. Staff interviews confirmed inconsistent understanding and application of PPE protocols for residents with infectious conditions. Hand hygiene practices were deficient during meal assistance, as staff were observed feeding multiple residents without performing hand hygiene between residents or after touching food items. Additionally, the facility did not maintain adequate documentation or procedures to prevent legionella growth, such as flushing unused toilets or maintaining complete temperature logs. Staff were unaware of specific protocols for legionella prevention, and there were missing records for several months, especially in unused areas of the facility.