Deficient Infection Control Practices and Incomplete Policy Implementation
Penalty
Summary
Surveyors identified multiple deficiencies in the facility’s infection prevention and control practices, particularly regarding the use of enhanced barrier precautions (EBP) and urinary catheter care. Certified nursing assistants (CNAs) were observed failing to consistently wear appropriate personal protective equipment (PPE) when providing care to residents on EBP, such as not donning gowns during high-contact activities like transfers. In one instance, a CNA transferred a resident with open wounds without wearing a gown, despite EBP signage and CDC guidance posted in the facility. Additionally, staff did not always perform hand hygiene after removing PPE or before assisting residents with personal items. The facility’s practices for urinary catheter care and storage were inconsistent with policy and infection control standards. Catheter collection bags were reused, stored in plastic trash bags tied to towel racks, and not always labeled or dated. Staff described and demonstrated cleaning procedures that varied from the written policy, including the use of an incorrect vinegar-to-water ratio for cleaning solutions and leaving cleaning solution in bags for extended periods. Supplies such as normal saline and syringes were found opened, unlabeled, and not properly stored or disposed of in resident rooms and supply areas. Several CNAs were unfamiliar with the revised catheter care policy, and documentation of staff education on new policies was incomplete. The facility’s infection prevention and control program lacked comprehensive written policies and procedures in several required areas. There was no documented system for infection surveillance, reporting communicable diseases, determining the duration and restrictiveness of isolation precautions, or prohibiting staff with communicable diseases from resident contact. The policies provided did not address these elements, and staff interviews confirmed the absence of written guidance, relying instead on verbal instructions or external resources. Expired and unlabeled medical supplies were also found in storage areas, further indicating lapses in infection control practices.