Failure to Maintain Infection Prevention and Control Program
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program as evidenced by multiple observed breaches in infection control practices. During a wound dressing change for a resident with functional urinary incontinence and a coccyx wound, a registered nurse did not perform hand hygiene between glove changes as required by facility policy. The nurse removed soiled gloves, failed to wash hands or use hand sanitizer, and then donned new gloves before continuing the dressing change process. The nurse acknowledged during interview that proper hand hygiene was not performed at each glove change. Additional deficiencies were observed regarding the implementation of droplet and contact precautions for residents with communicable diseases. One resident on enhanced droplet/contact precautions had signage indicating that staff should wear an N95 mask before entering the room. However, a certified medication technician entered the room without the required N95 mask and confirmed this lapse during interview. Another resident with C. diff was on contact precautions, with signage instructing staff to wear a gown and gloves. Both a dietary aide and a nursing assistant entered the resident's room without wearing the required personal protective equipment, and both acknowledged the failure to follow protocol during interviews. Interviews with the infection control preventionist and the director of nursing services confirmed that staff were expected to follow the posted infection control precautions, but there was no evidence provided that these precautions were consistently followed. The observed failures to adhere to established infection control policies and procedures contributed to the deficiency cited during the survey.