Failure to Implement Infection Control Program and Maintain Clean Equipment
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by staff not adhering to Enhanced Barrier Precautions (EBP) and by the presence of unclean medical equipment in the care environment. Specifically, staff members including LVNs and a CNA did not wear gowns as required during high-contact care activities such as incontinent care and linen changes for a resident on EBP. Observations revealed that no gowns were available in the resident's room or on the isolation cart, and staff interviews confirmed that the omission was due to forgetfulness, lack of supply, and unclear responsibility for restocking PPE. Additionally, both residents reviewed for infection control were observed to have feeding pump poles that were visibly dirty, with yellow and brown sticky substances present on the poles and the floor beneath them. Staff interviews indicated confusion regarding responsibility for cleaning the equipment, with nursing staff believing it was housekeeping's duty and housekeeping staff stating they only cleaned equipment upon request. The facility's policy required that portable equipment be kept clean to prevent the spread of infection, but this was not consistently followed. The residents involved had significant medical histories, including sepsis, pneumonia, pressure ulcers, dysphagia, stroke, and the use of feeding tubes and catheters. Care plans for both residents included EBP to reduce the transmission of multidrug-resistant organisms, with specific instructions for PPE use during high-contact activities. Despite these documented precautions, staff failed to consistently implement the required infection control measures, as evidenced by direct observation and staff admissions during interviews.