Failure to Maintain Infection Control Program and Use Sterile Technique
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, as evidenced by multiple instances where staff did not follow sterile technique during tracheostomy care and suctioning, and did not use enhanced barrier precautions as required. Observations and video reviews revealed that several nurses and CNAs performed tracheostomy care and suctioning on residents with tracheostomies without using sterile gloves or maintaining a sterile field, despite facility policy and standard clinical guidelines requiring sterile technique for these procedures. In some cases, staff touched non-sterile surfaces or equipment and continued with the procedure without changing gloves or performing hand hygiene. Additionally, staff did not consistently wear gowns or other PPE required for enhanced barrier precautions when providing care to residents with indwelling devices, wounds, or infections. Interviews with staff and review of records indicated that there was confusion and inconsistency regarding the use of sterile technique and enhanced barrier precautions. Some staff members reported that PPE and sterile supplies were not always available, and in such cases, they proceeded with care without the required equipment. The Interim DON and other staff acknowledged that they sometimes performed procedures without proper PPE or sterile supplies due to unavailability. Furthermore, not all staff were able to demonstrate knowledge of how to access PPE and sterile supplies, and some staff had not received adequate training or competency checks on infection control practices, including tracheostomy care and enhanced barrier precautions. The residents involved included individuals with complex medical needs, such as tracheostomies, feeding tubes, Foley catheters, wounds, and active infections. For example, one resident with a tracheostomy and multiple indwelling devices was observed receiving care without sterile technique or enhanced barrier precautions, and another resident with a Foley catheter and wound was cared for by CNAs who did not wear gowns as required. Medical records showed that several residents had active infections, including pneumonia, bacteremia, and catheter-associated urinary tract infections, and some had been recently hospitalized for these conditions. The facility's failure to follow its own infection control policies and procedures was confirmed through interviews, record reviews, and direct observation.
Removal Plan
- RN/DON A, Regional Nurse Consultant, and VP of Clinical Operations will deliver all following in service education to nurses one on one.
- RN/DON A was serviced by Facility Respiratory Therapist with documented competencies on file at the facility and kept in binders in the DON's office and Administrator's office.
- Nursing staff will be in-serviced on the proper procedure for enhanced barrier precautions and the policy and procedure for enhanced barrier precautions.
- All nursing staff will be in-serviced prior to them arriving to the facility for their next shift.
- The Director of Nursing, Regional nurse consultant, and VP of Clinical Operations will deliver all following in service education to nurses one on one.
- All facility staff will receive training on enhanced barrier precautions.
- Any staff who did not receive training on enhanced barrier precautions will receive this education prior to their next scheduled shift on the floor caring for residents.
- Residents #2, #3, #4, and #5 were assessed for complications and are currently being treated with antibiotics for active infections. The Interim DON performed new assessments for residents 3, 4, and 5.
- All nurses will be trained in suctioning and care of tracheostomy per sterile technique and suctioning of tracheostomy by RN/DON A who has been trained by the facility respiratory therapist and by the facility respiratory therapist.
- All nurses will be trained before they accept residents for their next scheduled shift.
- All nursing staff will be in-serviced prior to them arriving at the facility for their next shift.
- All facility staff will receive training on enhanced barrier precautions.
- Any staff who did not receive training on enhanced barrier precautions will receive this education prior to their next scheduled shift on the floor.