Failure to Maintain Infection Control and Enhanced Barrier Precautions
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by multiple observed breaches in infection control practices involving two residents and several staff members. Certified Nursing Assistants (CNAs) and a Licensed Vocational Nurse (LVN) were observed handling potentially contaminated items inappropriately, such as placing a used sheet back on a clean linen cart after providing incontinent care, and carrying used disposable wipes from a resident's room to a medication cart. Additionally, resident care items like wash basins and urinals were found unlabeled, unbagged, and improperly stored in resident bathrooms, contrary to infection control protocols. Staff members providing care to residents on Enhanced Barrier Precautions (EBP), including those with indwelling Foley catheters and feeding tubes, did not consistently wear the required personal protective equipment (PPE), such as disposable gowns and gloves. Observations revealed that EBP signage was missing from the doors of residents who required these precautions, and several staff members, including CNAs and LVNs, were unfamiliar with EBP protocols. The care plans for the affected residents did not include EBP measures, despite physician orders and diagnoses indicating the need for such precautions. Interviews with staff and review of facility policies confirmed a lack of understanding and inconsistent implementation of infection control and EBP protocols. Staff members admitted to not following proper procedures for labeling, bagging, and storing resident care items, and for donning appropriate PPE when providing direct care to residents with wounds, indwelling devices, or artificial openings. These failures were directly observed and acknowledged by staff, placing residents at risk for cross-contamination and infection.