Failure to Implement Infection Control Measures and Enhanced Barrier Precautions
Penalty
Summary
The facility failed to implement and maintain an effective infection prevention and control program, as evidenced by multiple observations and staff interviews. Laundry staff were seen transporting clean resident laundry throughout the facility without any covering, exposing the laundry to potential contamination as it was moved past residents and staff in the hallways. Additionally, the laundry staff sometimes carried laundered clothing on their shoulder and delivered bundles of clothing to multiple resident rooms, occasionally resulting in residents' clothing being placed in the wrong rooms. The supervisor of the laundry department confirmed that clean laundry was not covered during transport and was unaware of the requirement to do so. For one resident with significant medical conditions, including a stage 3 pressure ulcer and a wound vacuum, there was no evidence of Enhanced Barrier Precautions (EBP) being implemented or posted outside the resident's room. Staff interviews revealed a lack of knowledge about EBP among nursing and support staff, with some staff stating they did not know what EBP were and that isolation signage was not routinely used. The Director of Nursing also acknowledged unfamiliarity with EBP and recognized that some residents, including the one with a wound vacuum, would qualify for such precautions. No EBP signage was observed in the facility, and staff communication about precautions was inconsistent.