Failure to Implement and Enforce Infection Prevention and Control Program
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by multiple observations and staff interviews. Several staff members did not use appropriate personal protective equipment (PPE) when providing care to residents on enhanced barrier precautions (EBP), including during transfers, hygiene, and wound care for a resident with chronic diabetic wounds. The resident's room initially lacked EBP signage, and staff were observed assisting the resident without PPE, despite the facility's policy requiring gloves and gowns for high-contact care activities. Additionally, staff knelt on the floor during wound care without using a barrier, contrary to infection control protocols. Another resident on EBP for an ankle infection did not receive care in accordance with PPE requirements. A registered nurse assessed the resident's foot without gloves or a gown and later stated that PPE was only necessary for toileting, not for wound assessment, indicating a lack of understanding of EBP protocols. Furthermore, staff failed to sanitize blood pressure equipment and a stethoscope after use on a resident, and the nurse acknowledged that the equipment should have been sanitized but did not do so. The facility also did not adhere to CDC and Wisconsin Department of Health Services guidelines regarding staff return-to-work criteria following COVID-19 or gastrointestinal illness. Staff with COVID-19 or GI symptoms returned to work earlier than recommended, and the facility's documentation did not consistently record the date of last symptoms, making it difficult to verify compliance. The infection line lists and time clock records provided did not include necessary information to ensure staff met the required exclusion periods before returning to work.