Failure to Implement Infection Control Program and Precautions
Penalty
Summary
The facility failed to implement and maintain an effective infection prevention and control program as required by state and federal guidelines. For a period of eleven out of twelve months, there was no documented surveillance of infections, and the infection preventionist was unable to provide evidence of infection mapping or tracking. During interviews, the infection preventionist confirmed that no surveillance activities had been conducted for nearly a year, despite facility policies requiring systematic prevention, identification, and control of infections among staff and residents. One resident with a history of dementia, COPD, and hypertension exhibited symptoms consistent with COVID-19, including shortness of breath, wheezing, and low oxygen saturation. Despite these symptoms, there was no evidence that the resident was tested for COVID-19 or placed under droplet precautions as required. The resident continued to move throughout the unit without a mask, and staff interviews confirmed that isolation and testing protocols were not followed according to facility policy and regulatory guidance. Additional deficiencies were observed in infection control practices during resident care. An LPN failed to remove gloves and perform hand hygiene before handling wound care supplies and solutions after a dressing change for a resident with a sacral wound. In another instance, a resident with an order for enhanced barrier precautions did not have these precautions implemented during a high-contact activity, as the LPN did not wear a gown while flushing a nasogastric tube. These lapses were confirmed by staff interviews and direct observation.