Failure to Maintain Infection Prevention and Control Program
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, as evidenced by multiple observed lapses in infection control practices among staff during care of three residents. One certified nursing assistant (CNA) did not perform hand hygiene before donning gloves and failed to change gloves or sanitize hands when moving from dirty to clean tasks during incontinent care. The CNA also placed clean linens and a gown on the resident while still wearing contaminated gloves, contrary to facility policy and infection control standards. The CNA acknowledged during interview that these actions were incorrect and could lead to cross-contamination. A licensed vocational nurse (LVN) was observed performing wound care for a resident with a stage 4 pressure ulcer. The LVN did not change gloves or perform hand hygiene between cleaning the wound and applying a clean dressing, despite recognizing during interview that this was required to prevent infection. Facility records confirmed that the LVN had received training on proper wound care technique, including enhanced barrier precautions, prior to the incident. Additionally, the MDS Coordinator failed to wear a gown as required under enhanced barrier precautions while providing wound care to a resident with a chronic wound. The resident's care plan and physician orders specified the need for enhanced barrier precautions, including gown and gloves, during high-contact care. The MDS Coordinator admitted during interview that a gown should have been worn and that failure to do so could expose residents to infection. Facility policy and staff interviews confirmed that residents with chronic wounds require enhanced barrier precautions and that appropriate signage should be posted to indicate this requirement.