Failure to Maintain Infection Prevention and Control Practices
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by multiple lapses in infection control practices observed among staff caring for three residents with significant medical needs. Certified Nursing Assistants (CNAs) did not consistently perform hand hygiene after providing perineal care or before exiting resident rooms. For example, one CNA failed to wash or sanitize hands after pericare for a resident with a history of urinary tract infections and pneumonia, and another CNA did not perform hand hygiene between glove changes or after pericare, instead proceeding to touch common surfaces and assist the resident in communal areas. Staff also failed to adhere to Enhanced Barrier Precautions (EBP) as required for residents with wounds, indwelling medical devices, or other infection risks. Several CNAs did not wear gowns during high-contact care activities, such as changing briefs or emptying urinary catheters, despite EBP signage and care plans indicating the need for these precautions. In addition, a mechanical lift used for resident transfers was not sanitized between uses for different residents, increasing the risk of cross-contamination. Interviews with staff revealed misunderstandings about the application of EBP and inconsistent knowledge of proper infection control procedures. The residents involved had complex medical histories, including chronic wounds, indwelling catheters, colostomies, and frequent incontinence, placing them at increased risk for infection. Care plans and facility policies outlined specific interventions and precautions, such as regular hand hygiene, use of gloves and gowns, and disinfection of equipment, but these were not consistently followed. Staff interviews confirmed lapses in practice, with some CNAs citing being rushed or unaware of available supplies, and others misunderstanding the requirements for EBP. These failures were directly observed and documented by surveyors during the review period.