Infection Control Program Deficiencies and Lapses in Precautionary Practices
Penalty
Summary
The facility failed to maintain its infection prevention and control program as required, resulting in multiple deficiencies. Infection control surveillance reports and mapping were not completed for the months of May and June 2025, as confirmed by the Infection Preventionist (IP) and Director of Nursing (DON). The absence of these reports hindered the facility's ability to identify, investigate, and track infection patterns, which are necessary for planning interventions and staff training. The IP, who had recently started in the role, acknowledged that the reports had not been updated and emphasized the importance of monthly surveillance for infection control. Several residents with indwelling medical devices or wounds were not placed on Enhanced Barrier Precautions (EBP) as ordered by their physicians. For example, residents with Quinton catheters, indwelling urinary catheters, AV fistulas, and PEG/GT tubes did not have EBP signage outside their rooms, and staff were observed providing care without donning the required gowns. Staff members reported that they relied on signage to know when to implement EBP, and the lack of signage led to missed precautions. Additionally, staff were not consistently informed about which residents required EBP, resulting in improper use of personal protective equipment (PPE) during high-contact care activities. Other infection control lapses included staff refilling residents' water pitchers from bathroom sinks, which poses a risk of cross-contamination, and leaving personal items such as water jugs on the floor. Observations also revealed that trash bins were not emptied when full, and used washable gowns were not discarded properly. During medication administration, a nurse failed to don the required gown for a resident with a GT and did not perform hand hygiene or change gloves after picking up a dropped medication cup from the floor. These actions were in direct violation of the facility's infection control policies and procedures, as well as CDC guidelines.