Failure to Implement Infection Control Measures and Enhanced Barrier Precautions
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by multiple lapses in the cleaning and disinfection of glucose monitors and the implementation of Enhanced Barrier Precautions (EBP) for residents with specific medical needs. Observations revealed that an LPN did not disinfect the glucose monitor between uses for several residents, despite facility policy and CDC recommendations requiring disinfection after each use. The LPN was seen using the glucose monitor on multiple residents without cleaning it in between, and only wiped it down after several uses, contrary to the stated procedures. Interviews with staff indicated inconsistent understanding and practices regarding the appropriate cleaning agents and methods for disinfecting glucose monitors between residents. Additionally, the facility did not implement EBP for a resident with a peripherally inserted central catheter (PICC) line, despite physician orders and care plan interventions specifying the need for such precautions. Observations showed that there was no EBP signage or personal protective equipment (PPE) available at the resident's room, and a nurse accessed the resident's PICC line without wearing a gown. Interviews with staff revealed confusion about which residents required EBP and how these precautions should be communicated and implemented, with some staff relying solely on the presence of signage to determine precaution requirements. The residents involved included individuals with complex medical conditions, such as a resident with a psoas muscle abscess, cognitive communication deficit, and neuromuscular dysfunction of the bladder, who was receiving intravenous antibiotics through a PICC line. The lack of proper infection control measures and inconsistent application of EBP and disinfection protocols contributed to the facility's failure to provide a safe and sanitary environment and to prevent the transmission of communicable diseases and infections.