Infection Control Program Deficiencies and Lapses in Hand Hygiene
Penalty
Summary
Multiple deficiencies were identified in the facility's infection prevention and control program, as evidenced by direct observations and staff interviews. Staff members failed to perform hand hygiene at critical points during resident care, including before entering and after leaving resident rooms, before donning and after removing gloves, and between care tasks. For example, a CNA assisted a resident with mobility and food service without performing hand hygiene, and an LPN failed to sanitize hands before and after handling a resident's environment and administering medication. These lapses were observed across several residents, including those with indwelling medical devices and feeding tubes, where proper hand hygiene is essential. The facility also failed to ensure that infection prevention and control policies and procedures were reviewed annually as required. Several key policies, such as those for surveillance of infections, antibiotic stewardship, and vaccination, had not been updated or reviewed within the required timeframe. The infection preventionist and DON confirmed during interviews that these policies had not been reviewed or discussed in quality assurance meetings, and were not up to date with current standards. Additional deficiencies included improper management of soiled linens and expired eyewash station solutions. Observations showed soiled linens left unbagged on the floor and transported between resident rooms, contrary to facility policy. Eyewash stations in multiple locations contained expired saline solution bottles, which had not been replaced as required. Staff interviews confirmed that these practices did not meet facility expectations or policy requirements. Furthermore, staff failed to follow Enhanced Barrier Precautions for residents with indwelling devices, such as not wearing required PPE during high-contact care activities.