Failure to Maintain Infection Control Practices in Therapy Department
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, as evidenced by multiple observations of improper hand hygiene and equipment disinfection practices among therapy staff. Specifically, a physical therapist was observed wearing the same pair of gloves while touching multiple residents, their wheelchairs, gait belts, and walkers, without changing gloves or performing hand hygiene between contacts. Additionally, both the physical therapist and occupational therapist did not use hand hygiene before assisting residents or between resident contacts, and therapy equipment such as parallel bars was not disinfected between uses by different residents. Further observations revealed that the physical therapist had an open, uncovered cut on his finger while working with residents and used a paper towel to wipe sweat from his forehead and hands, then proceeded to touch residents without performing hand hygiene. Interviews with therapy staff indicated that they were aware of proper infection control practices but had not received facility-specific training or skill check-offs on infection control from the Director of Nursing (DON) or the facility. The DON, who serves as the infection preventionist, confirmed that the rehabilitation department had not been trained on infection control by the facility. Record reviews showed that therapy staff had completed online infection control modules provided by their contracting company, but these were annual refresher courses and not specific to the facility's policies or procedures. The facility's infection control policy requires all personnel to be trained on infection control upon hire and periodically thereafter, with oversight by the Quality Assurance and Performance Improvement Committee. Despite these requirements, the lack of facility-specific training and failure to follow basic infection control practices led to the observed deficiencies.