Failure to Implement and Enforce Infection Control Precautions
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, as evidenced by multiple lapses in infection control practices for three residents. For one resident with ESBL and MRSA infections, staff did not enforce proper contact precautions. The resident was observed repeatedly leaving and entering his room while on contact isolation, and was allowed to share a room with another resident not on precautions, despite available single rooms. Facility leadership and infection control personnel acknowledged the lack of a specific contact isolation policy and relied on CDC guidelines, but did not consistently implement them. Another resident with MRSA in the urine and a history of multiple infections was not properly protected by staff adherence to contact isolation protocols. A CNA was observed in the resident's room without wearing any PPE, touching surfaces and the resident's belongings, and failing to perform hand hygiene after contact. The CNA admitted to not knowing the specific reason for isolation and not wearing PPE because he believed he was not in direct contact with the resident. Interviews with other staff revealed inconsistent understanding of isolation procedures and hand hygiene requirements. A third resident, who required Enhanced Barrier Precautions (EBP) due to a cholecystectomy drain, did not receive appropriate infection control measures during blood sugar checks and insulin administration. The nurse wore gloves but failed to don a gown as required by EBP protocols, despite signage and facility policy. Interviews with the nurse and DON confirmed a misunderstanding of when gowns were required under EBP, and that training had been provided but was not effectively implemented. Facility policies referenced CDC guidelines and EBP requirements, but staff actions did not consistently align with these standards.