Infection Control Failures in COVID-19 Management, Precautions, and Laundry Handling
Penalty
Summary
The facility failed to implement and maintain an effective infection prevention and control program, as evidenced by multiple deficiencies in COVID-19 management, transmission-based precautions, enhanced barrier precautions, communication of pertinent clinical information, and laundry handling. Employees who tested positive for COVID-19 returned to work before meeting CDC criteria for healthcare personnel, including the absence of required negative tests and insufficient isolation periods. The facility also did not conduct appropriate outbreak testing for staff and residents during three separate COVID-19 outbreaks, and testing logs did not align with CDC guidelines regarding timing and inclusion of vaccinated staff. Transmission-based precautions were not properly followed for a resident with a urinary tract infection caused by MRSA. Staff failed to don required personal protective equipment, such as gowns, when entering the resident's room and did not use dedicated equipment, resulting in potential contamination of shared medical equipment and surfaces. Additionally, enhanced barrier precautions were not observed during wound care for another resident, as staff did not use gowns and failed to perform hand hygiene between glove changes, contrary to facility policy and CDC recommendations. The facility also lacked a process to obtain and communicate pertinent clinical information following a resident's acute care hospital treatment for a urinary tract infection, resulting in the continued administration of an antibiotic that was not the most effective for the identified organism. Furthermore, the handling and processing of residents' personal laundry did not adhere to infection control standards, with soiled laundry stored in open, unlidded hampers and staff not using appropriate protective equipment or following manufacturer guidelines for laundry processing. These failures were confirmed through staff interviews, record reviews, and direct observations.