Deficiencies in Infection Control Practices and Documentation
Penalty
Summary
Multiple deficiencies in infection prevention and control practices were identified through observations, interviews, and record reviews. Staff failed to maintain separation between clean PPE isolation carts and soiled disposable gown hampers in several resident rooms, with the hampers often touching the carts and, in some cases, overflowing and preventing lids from closing. These lapses were observed for multiple residents on enhanced barrier precautions (EBP) due to conditions such as indwelling urinary catheters, wounds, and gastrostomy tubes. Staff, including RNs and CNAs, acknowledged that the soiled gown hampers should not be in contact with PPE carts due to the risk of contamination, but the issue persisted across several rooms. Further deficiencies were noted in the facility's infection surveillance documentation. The onset dates of infections for two residents were inaccurately recorded on the Infection Prevention and Control Surveillance Log, with staff using the date antibiotics were started rather than the actual onset of infection symptoms. Additionally, pending culture results for several residents were not updated in the surveillance logs, and in one case, there was no documentation of follow-up for a canceled culture. The Director of Staff Development/Infection Preventionist (DSD/IP) and DON confirmed these documentation errors during interviews and acknowledged that the logs should have been completed accurately and updated in a timely manner. Hand hygiene practices were also found to be deficient. A CNA was observed failing to perform hand hygiene after delivering a food tray to a resident on EBP and before delivering a tray to another resident. The CNA admitted to forgetting to sanitize hands between tasks, and the DSD/IP confirmed that hand hygiene should have been performed according to facility policy. These failures in infection control practices, documentation, and hand hygiene were verified by facility leadership and staff during the survey.