Failure to Implement and Maintain Infection Control Practices
Penalty
Summary
The facility failed to implement and follow infection prevention and control practices in several instances. For one resident with a wound positive for MRSA, contact precautions were not initiated immediately upon identification of the multidrug-resistant organism (MDRO), despite facility policy requiring prompt initiation of transmission-based precautions. Although a contact precautions sign was eventually posted, there was a delay in placing the order and implementing the necessary precautions as soon as the culture results were received. In another instance, dirty linen barrels and a rolling commode were found stored in a clean shower area, rather than in the designated dirty utility area. The facility was unable to provide a policy regarding the proper storage of dirty items when requested. Additionally, in a resident's shared bathroom, an unlabeled urinal was found in the sink next to uncovered oral hygiene items, and another set of unlabeled hygiene items was found stored on top of a toilet lid. Staff confirmed that these items should have been labeled and stored at the resident's bedside or in the bedside cabinet, not in the bathroom or on the toilet. The facility also failed to implement Enhanced Barrier Precautions (EBP) in a timely manner for a resident with a wound vac. Although an order for EBP was eventually placed, there was a significant delay after the wound vac was ordered, and signage indicating EBP was not consistently present on the resident's door. The resident reported that staff had not consistently worn gowns when providing hygiene or wound care, and staff interviews confirmed that EBP requires the use of gowns and gloves for high-contact care activities. Facility policy states that EBP should be in place for residents with wounds or indwelling devices, with appropriate signage and personal protective equipment readily accessible.