Infection Control Deficiencies: Policy Review, Equipment Disinfection, and PPE Use
Penalty
Summary
The facility failed to ensure that its Infection Prevention and Control Program (IPCP) policies and procedures were reviewed annually as required. The Infection Control Program policy was last reviewed on 10/24/2022, despite the policy stating that reviews should occur at least annually. Interviews with the Infection Preventionist, Director of Nursing, and Administrator confirmed that the policy had not been reviewed within the required timeframe, even though all acknowledged the expectation for annual review. During observations, a resident with a diagnosis of obstructive uropathy and an ostomy was found lying in bed with their urinary catheter drainage bag touching the floor. Staff entering the room did not correct the issue, and the Certified Nursing Assistant (CNA) later admitted that the drainage bag should not have been on the floor but did not know how it happened. Both the Registered Nurse Unit Manager and the Director of Nursing confirmed that catheter drainage bags should not touch the floor, as this is an infection control issue. Additionally, staff failed to disinfect or sanitize medical equipment between resident use. A CNA was observed moving a sit-to-stand lift from one resident's room to another without cleaning or disinfecting it, only wiping the handle with an adult washcloth and not using the proper disinfectant wipes. Furthermore, staff did not consistently follow Enhanced Barrier Precautions (EBP) for residents on EBP, as staff were observed transferring residents without wearing the required gowns and gloves and, in one instance, not performing hand hygiene after care. Staff interviews confirmed that the expected protocols for PPE and equipment disinfection were not followed.