Failure to Ensure Proper Infection Control Practices and Removal of Expired Supplies
Penalty
Summary
The facility failed to follow infection control practices in two main areas. First, a sitter providing supervision to a resident on enhanced barrier precautions (EBP) did not wear the required personal protective equipment (PPE) while in the resident's room. The resident had diagnoses including heart failure and metabolic encephalopathy, was not oriented to time, and had poor recall. Observations showed that PPE was available both outside and inside the room, but the sitter was unaware of the need to use PPE and stated there was no sign indicating EBP. Facility staff interviews revealed that the facility was not informed by the family about the sitter's presence, and the sitter had not received orientation or education on infection control or EBP requirements. Staff acknowledged that this situation placed the resident at risk of cross-contamination. Second, the facility failed to ensure that expired infection control supplies were removed from use. Observations found expired hand sanitizer, COVID-19 test kits, and disposable gloves in various locations, including hallways, storage rooms, and medication carts. Staff interviews confirmed that expired hand sanitizer would be ineffective, expired COVID-19 test kits could give inaccurate results, and expired gloves would not provide adequate protection and could cause skin irritation. Staff also stated that it was their responsibility to check for expired items, but multiple expired supplies were still present throughout the facility. A review of the facility's policies indicated that standard and enhanced barrier precautions should always be used when caring for residents, and that staff, visitors, and sitters should be educated on infection control practices. Policies also required that expired or damaged supplies be removed from service immediately. Despite these policies, the facility did not ensure that all individuals were properly educated or that expired supplies were consistently removed, resulting in deficiencies in infection prevention and control.