Failure to Implement Infection Control Measures and Track XDROs
Penalty
Summary
The facility failed to implement and maintain proper infection prevention and control measures in several key areas. During a survey, it was observed that staff did not consistently bag or secure soiled linen and resident clothing before sending them down the laundry chute, resulting in loose items falling into collection bins. Additionally, clean linen and resident clothing were transported in uncovered carts, contrary to facility policy. Interviews with the laundry attendant and infection preventionist confirmed that these practices were not always followed, and staff acknowledged that linen should be bagged or covered during transport to prevent contamination. The facility also failed to track and report cases of extensively drug-resistant organisms (XDROs) as required by state regulations. The infection preventionist and director of nursing both stated that they had not been tracking or reporting XDROs to the appropriate registry, despite regulatory requirements and facility policy. This lack of tracking and reporting was confirmed through interviews and review of facility documentation. Furthermore, staff did not adhere to enhanced barrier precautions (EBP) for a resident with an indwelling suprapubic catheter. Two certified nursing assistants were observed transferring the resident without wearing the required gown and gloves, despite clear signage and physician orders indicating the need for EBP. The infection preventionist and LPN confirmed that staff should have worn appropriate PPE during high-contact care activities for residents on EBP. The resident's care plan and physician orders documented the need for these precautions, but the facility's EBP list did not include the resident, indicating a lapse in communication and documentation.