Infection Control Program Deficiencies and Lapses in Precaution Implementation
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program as evidenced by multiple deficiencies observed during survey. The infection preventionist was not calculating baseline rates of infections for prevalent infections, instead only tracking an overall infection rate. This omission was confirmed during interviews and review of infection control documentation, where it was noted that individual rates for specific infections were not being tracked until after the surveyor's inquiry. Additionally, the facility did not consistently flush the eye wash station weekly as required, with documentation missing for two weeks in May and no designated backup staff to perform the task in the primary staff member's absence. Several residents with stage 2 pressure injuries or other qualifying conditions were not placed on Enhanced Barrier Precautions (EBP) as required by facility policy. For example, one resident with a stage 2 coccyx pressure injury was not on EBP, and staff were observed providing personal care and wound treatment without wearing gowns or following proper PPE protocols. Similar lapses were observed with other residents who had stage 2 pressure injuries, where EBP signage and PPE were not present, and staff were not aware of or did not implement EBP. Interviews with staff revealed a lack of clarity regarding which wounds required EBP and who was responsible for initiating these precautions. Hand hygiene deficiencies were also identified, particularly during medication administration. A nurse was observed failing to perform hand hygiene before donning gloves and between tasks, including when handling medications and administering eye drops. Additionally, a resident with an indwelling catheter was repeatedly observed with the catheter bag and tubing resting directly on the floor without a privacy cover or barrier, contrary to facility policy and infection control standards. These failures in infection prevention practices had the potential to affect all residents in the facility.