Failure to Implement Infection Prevention and Control Program
Penalty
Summary
The facility failed to implement an effective infection prevention and control program as evidenced by improper handling and availability of personal protective equipment (PPE) for residents on isolation or enhanced barrier precautions. In one instance, a face shield was found hanging inside a resident's room after the resident had been cleared from COVID-19 isolation, with no labeling or dating, and no sign indicating isolation precautions. Staff interviews confirmed that the face shield should have been removed once isolation was discontinued, and its presence could have led to cross-contamination. Review of facility policy indicated that transmission-based precautions and associated PPE should be clearly identified and removed when no longer necessary. Additionally, seven residents on Enhanced Barrier Precautions (EBP) did not have PPE, such as gowns and gloves, available immediately outside their rooms, despite signage indicating EBP status. Observations and interviews with the Infection Preventionist, DON, and Administrator confirmed the absence of required PPE outside these rooms, which was not in accordance with CDC guidelines and facility policy. Facility documents and policies reviewed stated that PPE and alcohol-based hand rub should be readily accessible to staff when EBP is in place.