Failure to Implement Effective Infection Prevention and Control Program
Penalty
Summary
The facility failed to implement an effective infection prevention and control program as evidenced by multiple observed lapses in hand hygiene and glove use among staff during medication administration and food service. Specifically, a nurse was observed not performing hand hygiene after removing gloves and before entering a resident's room to administer intravenous antibiotics. Food service staff were seen entering the kitchen without washing hands, wearing gloves improperly, and failing to change gloves or perform hand hygiene between different food handling tasks. Additionally, during medication administration to two residents, a nurse did not perform hand hygiene or change gloves between tasks such as administering oral medications, subcutaneous injections, and applying topical creams, despite facility policy requiring hand hygiene before and after patient contact and after glove removal. The facility's water management plan was found to be inadequate, lacking specific testing protocols, acceptable ranges for control measures, and corrective actions when control limits are not maintained to prevent the growth of waterborne pathogens such as Legionella. The acting maintenance supervisor was unable to explain the laboratory tests being conducted on water samples and there was no documentation of annual review of the water management program. The policy did not address necessary control measures or corrective actions, and staff were not familiar with the requirements for monitoring and responding to changes in water quality or potential Legionella contamination. Staff training and education on infection control were also deficient. There was no documented evidence of infection control education or in-service training for staff since 2023, and only a small fraction of employees had updated COVID-19 vaccination status. The facility's policy on COVID-19 vaccination did not include requirements for providing staff education on the benefits, risks, and potential side effects of the vaccine. Interviews with staff confirmed the lack of recent infection control training and incomplete education regarding COVID-19 vaccination.