Failure to Implement Infection Control Practices and Enhanced Barrier Precautions
Penalty
Summary
The facility failed to implement proper infection prevention and control practices in several instances. Two empty antibiotic IV bags, labeled with a previous date, were observed hanging on an IV pole instead of being promptly removed and discarded after use. Both a licensed vocational nurse and the infection preventionist confirmed that these items should have been removed immediately to prevent potential cross-contamination and the accumulation of bacteria. Additionally, there was no Enhanced Barrier Precaution (EBP) signage or available personal protective equipment (PPE) near the room of a resident with paraplegia and an indwelling catheter, despite the care plan requiring such measures. Staff interviews confirmed that the absence of signage and PPE could result in staff and non-staff being unaware of the necessary precautions before entering the room. In another instance, two non-staff transporters entered the room of a resident with end stage renal disease, who was on EBP due to an indwelling catheter, without wearing the required PPE while attempting to transfer the resident. The infection preventionist stated that proper PPE should have been worn during this high-contact activity, as indicated by the resident's care plan and facility policy. These lapses in infection control practices were directly observed and confirmed through staff interviews and record reviews.