Failure to Adhere to Infection Control Protocols for Residents on Precautions
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, as evidenced by multiple lapses in staff adherence to established protocols for residents on Enhanced Barrier Precautions (EBP) and droplet precautions. For one resident with a tracheostomy and a history of laryngeal cancer, hemiplegia, COPD, and other conditions, staff did not consistently use the required personal protective equipment (PPE) when entering the room during the use of a nebulizer or humidified air. Observations showed that an LPN entered the resident's room wearing only a gown and gloves, omitting the N95 mask and eye protection required by both facility policy and the droplet precautions signage. Similarly, a CNA was observed wearing a regular mask without eye or face protection. Both the Infection Preventionist and the Director of Nursing confirmed that the expectation was for staff to wear N95 masks and eye protection under these circumstances. In another instance, a resident with an indwelling urinary catheter and a history of urinary infection was observed with their uncovered catheter bag lying directly on the floor on more than one occasion. The resident's care plan specified the use of enhanced barrier precautions during high-contact activities, including device care. Despite this, the catheter bag was seen on the floor both in a covered and uncovered state, and staff interviews revealed that this was a recurring issue due to the bed frame configuration. The Infection Preventionist and Director of Nursing acknowledged that the catheter bag should not be uncovered or in contact with the floor. These deficiencies were identified through direct observation, staff interviews, and review of facility policies and resident records. The facility's failure to ensure proper PPE use and maintain sanitary conditions for medical devices did not align with their own infection control policies and placed residents at increased risk for the development and transmission of communicable diseases and infections.