Deficiencies in Infection Control: EBP Signage, DME Cleaning, and Hand Hygiene
Penalty
Summary
The facility failed to implement and maintain an effective infection prevention and control program, specifically regarding enhanced barrier precautions (EBP), cleaning and disinfection of durable medical equipment (DME), and proper hand hygiene and glove use. Surveyors found that residents requiring EBP did not have clear signage or instructions indicating the required personal protective equipment (PPE) or which care activities necessitated specific PPE. Instead, rooms were marked only with a magnetic square labeled 'EP,' without further information. Staff interviews revealed inconsistent understanding of EBP requirements, with some staff unsure of what PPE to use or the meaning of the signage. Additionally, EBP was inconsistently documented, sometimes only in care plans and not in physician orders, and there was no clear indication at the door for which resident in a shared room was under EBP. Observations showed that staff did not consistently follow protocols for cleaning and disinfecting DME between residents. For example, an LPN used the same finger pulse oximeter, blood pressure cuff, and forehead thermometer on two different residents without cleaning the equipment in between, despite being aware of the policy requiring disinfection. The DON confirmed that all DME should be cleaned between uses, and the facility's policy also required this practice. Hand hygiene and glove use were also found to be deficient. During incontinence care, a CNA failed to change gloves and wash hands between caring for two different residents in the same room. The CNA admitted to not following proper procedure, stating it was not her normal practice. The facility's hand hygiene policy required handwashing or use of hand sanitizer before and after resident contact, after removing gloves, and after contact with bodily fluids, but this was not followed during the observed care.