Infection Control Deficiencies: Incomplete Surveillance, Improper Isolation, and Unsanitary Wound Care
Penalty
Summary
The facility failed to maintain a comprehensive infection prevention and control program as evidenced by incomplete infection surveillance reports, improper implementation of contact isolation precautions, and unsanitary wound care practices. Infection surveillance reports for the past three months were found to be incomplete, missing critical information such as infection type, signs and symptoms, pharmacy orders, and comments. The Assistant Director of Nursing and Infection Preventionist acknowledged that the reports were not being fully utilized as intended, and the Regional Nurse Consultant confirmed that all necessary information should be documented to effectively track and trend infections. A resident with a history of congestive heart failure, type 2 diabetes mellitus, and an extended spectrum beta-lactamase resistant infection (ESBL) was not placed on contact isolation as ordered by the physician. Instead, the resident was on enhanced barrier precautions, and the appropriate signage for contact isolation was not present on the resident's door. The resident reported that staff did not consistently use personal protective equipment (PPE) during care, and the facility's list of residents on contact isolation did not include this individual, despite a physician's order and policy requirements for contact precautions in cases of multidrug-resistant organisms. Additionally, wound care for another resident with pressure ulcers was performed in an unsanitary manner. The wound care nurse failed to perform hand hygiene between glove changes and used scissors that were not sanitized, placing them on the resident's bed linens and using them to cut wound care materials. The presence of a fly in the resident's room during wound care was also observed, and the Assistant Director of Nursing and Infection Preventionist confirmed that these practices did not meet infection control standards and could contribute to wound infection.