Infection Control Policies and Procedures Not Accessible at Nurse's Stations
Penalty
Summary
The facility failed to ensure that infection control (IC) policies and procedures were available at all four nurse's stations as required. During observations and interviews, staff members at each nursing station, including an LVN, RN, Infection Preventionist Nurse (IPN), and Assistant Director of Nursing (ADON), were unable to locate the IC policy and procedure binder in their respective stations. The IPN confirmed that the IC policies and procedures were kept inside the IPN's office rather than being accessible at each nursing station. Staff reported that, in the absence of the binder, they would consult the Director of Nursing (DON) for guidance on infection control matters. The DON acknowledged that the facility's IC policies and procedures should be present at all nursing stations to provide staff with immediate access to guidelines for proper care and treatment, especially during an outbreak or infection control issue. The lack of readily available IC policies and procedures at the nurse's stations had the potential to deprive nursing staff of important information necessary for infection control practices.
Plan Of Correction
C1280 Nursing Service--Patients with Infectious Dis How corrective action will be accomplished for those residents found to have been affected by the identified practice: Immediate Corrective action(s) for resident(s) found to have been affected by the deficient practice: - On 9/24/25, copies of the current Facility Infection Control Policies and Procedures Manual were printed and placed at all four nursing stations by the Infection Preventionist. How the facility will identify other residents having the potential to be affected by the same identified practice and what corrective action will be taken: - On 9/24/25, the Infection Preventionist (IP) verified that all four nursing stations contained the Infection Control Policies and Procedures Manual. - No other residents were affected by this deficient practice. What measures will be put into place or what systemic changes will the facility make to ensure that the identified practice does not recur: - On 9/24/25 and 10/10/25, the Infection Preventionist (IP) conducted an in-service training to educate staff on the location and accessibility of the facility's Infection Control Policies and Procedures Manual. - Starting 10/14/25, the Infection Preventionist will monitor the availability of the Infection Control Policies and Procedures manual at each nursing station 2x/week for three months to ensure accessibility for all staff. How the facility plans to monitor its performance to make sure that solutions are sustained: - The plan must be implemented, and the corrective action evaluated for its effectiveness. - The POC is integrated into the quality assurance system. - The Infection Preventionist will be reporting the results of the monitoring to the QA committee monthly x 3 months for review and recommendations and ensure substantial compliance is sustained. Any deficient practices will be corrected immediately and discussed during QA committee meetings to identify root cause and action plan to prevent any further deficient practices.