Failure to Maintain Infection Control and Adhere to PPE Protocols
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program as evidenced by multiple observed deficiencies. For two residents, the environment was not kept clean to prevent the transmission of communicable diseases. One resident with a urinary catheter was observed with a leaking catheter bag, resulting in a puddle of urine on the floor beneath the bed. Staff interviews confirmed that both nurses and aides were expected to address such issues promptly, but the leak was not managed in a timely manner. Additionally, a resident's mattress cover was found to be missing a large piece, making it impossible to disinfect the mattress. Staff acknowledged that such issues should be reported to maintenance, but the problem was not logged as required. The facility also failed to follow proper use of personal protective equipment (PPE) and enhanced barrier precautions (EBP) for residents on transmission-based precautions. One resident with a history of multidrug-resistant bacteria had EBP signage posted, but a certified nursing assistant provided high-contact care without wearing a gown as required. Another resident requiring stoma care was attended to by a registered nurse who wore a gown, gloves, and mask, but failed to use eye protection during suctioning, despite knowing it was expected per facility policy. These lapses in following standard and enhanced precautions were confirmed through staff interviews and direct observation.