Failure to Implement and Maintain Infection Prevention and Control Program
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program for several residents requiring Enhanced Barrier Precautions (EBP). Surveyors observed that signage indicating the need for personal protective equipment (PPE) was missing from the doors of four residents who had conditions such as open wounds, indwelling catheters, and pressure ulcers. Additionally, PPE bins were not present at these residents' doors, and staff were not consistently informed or aware of which residents required EBP. Staff interviews revealed a lack of understanding regarding EBP, with some CNAs stating they had never been instructed to wear gowns for high-contact care or catheter care for these residents. Direct observations showed that staff, including the ADON, did not wear appropriate PPE such as gowns while performing high-contact care activities like wound care, dressing, and bathing for residents with open wounds or indwelling catheters. In one instance, the ADON performed wound care on a resident's left heel without changing gloves or performing hand hygiene after removing a soiled dressing, thereby contaminating the wound. The ADON also did not wear a gown during this procedure, and similar lapses were observed during care for other residents requiring EBP. Review of the facility's policies indicated that PPE should be used as needed during wound care, and that infection control policies were intended to prevent and manage transmission of diseases. However, the facility was unable to provide current hand hygiene and EBP policies when requested. Interviews with staff and management confirmed that there had been no recent in-service training on EBP, and that responsibilities for ensuring PPE availability and signage were unclear or not consistently followed. These failures were observed for residents with significant medical needs, including chronic wounds, indwelling catheters, and other conditions requiring strict infection control measures.