Infection Control Program Deficiencies Related to Labeling and PPE Use
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program for multiple residents, as evidenced by several observed deficiencies. For one resident with a gastrostomy tube (G-tube), the feeding bottle and water flush bag were not labeled with the date and staff initials, contrary to facility policy requiring these items to be changed and labeled every 24 hours. Multiple staff, including an LVN, RN, and the Infection Preventionist (IP), confirmed the absence of required labeling, acknowledging that this omission made it difficult to determine when the equipment was last changed. Additionally, for ten residents with suction tubes connected to mechanical ventilators or artificial airways, the tubing was not labeled with the date and initials as required by policy. Observations revealed that suction tubing at the bedside of these residents lacked any labeling, and both the respiratory therapist and IP confirmed this was not in compliance with facility procedures. The policy specified that disposable equipment, such as inline suction catheters, must be changed every 24 hours and labeled accordingly, but this was not followed. The facility also failed to ensure proper use of personal protective equipment (PPE) during high-contact care activities. Staff were observed administering medications through G-tubes and performing transfers without wearing gowns as required under Enhanced Barrier Precautions (EBP) for residents with indwelling medical devices. In one instance, a CNA wore a gown improperly, using it as an apron without the sleeves during a resident transfer after a shower. Interviews with staff and the IP confirmed that gowns and gloves were required during these activities, and that the observed practices did not align with facility policy or EBP guidelines.