Failure to Implement Infection Control Procedures and Equipment Disinfection
Penalty
Summary
Facility staff failed to adhere to appropriate infection prevention and control procedures, specifically in the use of Enhanced Barrier Precautions (EBP) and the cleaning of mechanical lifts. Observations revealed that staff did not wear required personal protective equipment (PPE), such as gowns and gloves, during the provision of care for two residents with wounds who required EBP. Additionally, there were no EBP signs on the residents' doors to alert staff of the necessary precautions, and staff interviews indicated confusion about who was responsible for ensuring signage and PPE availability. The care plans for these residents either lacked direction for EBP or were not properly implemented, and staff admitted to not following EBP protocols due to the absence of signage. Further deficiencies were noted in the cleaning and disinfection of mechanical lifts used for resident transfers. Staff were observed transferring two residents using mechanical lifts without sanitizing the equipment before or after use, contrary to facility policy and manufacturer guidelines. Interviews with staff revealed a lack of awareness or understanding regarding the need to disinfect the lifts between uses, with some staff only performing this task for residents known to be COVID-positive. The Director of Nursing and Administrator both stated that lifts should be sanitized before and after each use, but there was no consistent practice or clear policy enforcement observed. The residents involved in these deficiencies were assessed as having moderate to severe cognitive impairment and were dependent on staff for care, including wound care and transfers. The facility's policies required EBP for residents with wounds or indwelling devices and mandated staff training and competence in infection control practices. However, the lack of proper signage, inconsistent use of PPE, and failure to disinfect equipment contributed to the observed lapses in infection prevention and control.