Failure to Track Infections and Maintain Infection Control Practices
Penalty
Summary
The facility failed to adequately track infections and maintain infection control measures, as evidenced by a lack of proper documentation and tracking of COVID-19 cases for multiple residents over a three-month period. Although several residents tested positive for COVID-19 in January, February, and March 2025, their infections were not documented in the infection control logs or the COVID-19 line list for those months. The Director of Nursing, who also served as the Infection Control Preventionist, confirmed that without accurate tracking and documentation, staff, residents, and visitors could not ensure appropriate care and services to prevent the spread of COVID-19. This failure was verified during interviews and through review of facility records and CDC guidance, which emphasized the need for processes to identify and manage individuals with suspected or confirmed COVID-19 infection. Additionally, the facility did not ensure proper infection control practices during blood glucose testing for a resident with a history of atherosclerotic heart disease and type II diabetes mellitus. Observation revealed that a registered nurse did not perform hand hygiene before donning gloves, did not use a barrier for glucometer supplies, and failed to perform hand hygiene after glove removal and before applying new gloves. Both the nurse and the Director of Nursing confirmed these lapses, which were inconsistent with facility policies requiring hand hygiene before and after glove use and the use of a clean barrier for equipment during procedures.