Failure to Implement Proper Infection Control Signage and Equipment Cleaning
Penalty
Summary
The facility failed to ensure proper implementation of infection prevention and control protocols for residents on transmission-based precautions (TBP) and during the use of shared medical equipment. For one resident admitted with a history of parvovirus infection, the care plan and physician orders specified strict droplet isolation, including the use of personal protective equipment (PPE), signage on the door, and in-room care. However, observations revealed that there was no signage on the resident's door indicating TBP status or the type of precautions required. Interviews with staff members, including a CNA and LPN, confirmed uncertainty about the resident's isolation status and the absence of appropriate signage. The infection control designee also verified that the admitting nurse should have placed the correct signage and communicated the TBP type and reason during shift reports. Facility policies reviewed did not address requirements for signage or staff/visitor awareness of TBP type. Additionally, the facility did not ensure that medical equipment, specifically a vital signs monitor and blood pressure cuff, was properly sanitized between use with different residents. An LPN was observed using the same blood pressure cuff on two residents without cleaning it before or after use, despite the availability of sanitizing wipes. The residents involved had significant medical histories, including immunocompromised status and chronic illnesses, increasing their vulnerability to infection. The LPN acknowledged the failure to sanitize the equipment during an interview. These deficiencies were identified through medical record review, direct observation, staff interviews, and policy review. The findings affected one resident on TBP and two residents observed for infection control practices with shared equipment, out of a facility census of 88. The facility's policies lacked specific guidance on signage and communication of TBP requirements, contributing to the observed lapses in infection prevention and control.