Failure to Implement Infection Control and Precautionary Measures
Penalty
Summary
The facility failed to follow its own infection prevention and control policies, as well as CDC guidelines, in several key areas. Two residents with indwelling medical devices (tessio catheters for dialysis) did not have physician orders or care plan interventions for Enhanced Barrier Precautions (EBP) as required. Observations confirmed the absence of EBP signage and documentation for these residents, and the Director of Nursing acknowledged the omission. Both residents had significant medical histories, including end stage kidney disease and dependence on dialysis, which necessitated the use of indwelling catheters. Additionally, the facility did not implement appropriate transmission-based (Contact) precautions for four residents who tested positive for norovirus. Despite positive lab results and physician documentation indicating concern for norovirus, there was no evidence in the clinical records that these residents were placed on Contact Precautions as required by facility policy and CDC guidelines. The Infection Preventionist confirmed that these precautions were not implemented for the affected residents. The facility also failed to maintain an ongoing infection surveillance program, as required by its own policies and the job description of the Infection Preventionist. Infection control documentation was missing for two out of ten months, and the DON confirmed the lack of surveillance during those periods. Furthermore, during a medication pass, an LPN was observed removing and applying a lidocaine patch to a resident without using gloves, which was confirmed by the staff member. This failure to use appropriate personal protective equipment during medication administration represents a lapse in infection control practices.