Failure to Adhere to Infection Control Protocols and Precautions
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by multiple instances where staff did not adhere to established protocols for Transmission-Based Precautions (TBP) and Enhanced Barrier Precautions (EBP). Observations revealed that staff entered rooms of residents on Contact Precautions without donning required personal protective equipment (PPE) such as gowns and gloves, despite clear signage and facility policy. For example, a Certified Occupational Therapy Assistant entered a resident's room without PPE, and a Certified Nurse's Assistant delivered a meal tray without performing hand hygiene or wearing PPE as directed by posted instructions. Further deficiencies were noted in the application of EBP and the management of residents with specific infection risks. One resident with a PICC line was observed with an incorrect Contact Precautions sign instead of the required EBP sign, and both staff and the resident did not consistently use PPE when outside the resident's room. Another resident with a urostomy bag experienced ongoing leakage, with soiled linens left in the room and not promptly removed, contrary to infection control expectations. Family members also reported and observed lapses in maintaining a clean and sanitary environment for this resident. Additional lapses included improper handling of shared equipment, such as an ice scoop being used by visitors without hand hygiene or gloves, and staff confusion regarding the correct application of precautions for both residents and housekeeping tasks. Interviews with staff confirmed a lack of understanding and inconsistent implementation of the facility's infection control policies, including the use of correct signage and PPE requirements for both staff and visitors.