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F0880
D

Failure to Maintain Effective Infection Control Program and Transmission Based Precautions

Haverford, Pennsylvania Survey Completed on 09-03-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to maintain an effective infection control program, specifically regarding Transmission Based Precautions for two residents. Facility policy requires a qualified Infection Preventionist (IP) to be present at least part-time, participate in the Quality Assessment and Assurance committee, and oversee the infection prevention and control program. However, interviews with the Director of Nursing and Nursing Home Administrator revealed that there was no IP currently in the building, and the facility relied on a regional RN who only visited a couple of times a month. Documentation showed the IP had not attended recent QAPI meetings and had not been present in the facility since early August, despite a high frequency of infections noted in the facility assessment. Clinical record reviews for two residents showed both required Enhanced Barrier Precautions due to conditions such as a suprapubic catheter and urinary tract infection. Observations found that while signage for Enhanced Barrier Precautions was posted on their room doors, the isolation supply bins outside their rooms lacked necessary equipment, including gowns and gloves. A registered nurse confirmed the absence of required isolation supplies, indicating a failure to implement proper infection control measures as outlined in facility policy.

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