Failure to Adhere to Infection Control Practices and Documentation
Penalty
Summary
The facility failed to ensure adherence to infection prevention and control practices in several key areas. Four out of five sampled residents did not receive COVID-19, pneumonia, and influenza vaccines as required, despite some having provided verbal consent for vaccination. Documentation was lacking in the residents' medical records to confirm administration of these vaccines, and there was no evidence of consent or declination for the pneumonia vaccine. The Director of Nursing confirmed that there was no documentation in the electronic or physical charts to show that the vaccines were administered, and was unsure why the vaccinations were not given even when consent was obtained. Staff members, including two CNAs and an LVN, were observed not adhering to proper infection control protocols. One CNA entered a COVID isolation room without performing hand hygiene and without donning the required PPE, aside from an N95 mask. This CNA also improperly handled contaminated linen by carrying it into the hallway instead of placing it in the designated hamper inside the isolation room. Both the CNA and LVN admitted to not being fit tested for the N95 masks they were wearing, and the facility's fit testing binder lacked current documentation for these staff members. The Director of Nursing acknowledged that fit testing should be conducted annually and upon hire, but records were incomplete or outdated. Housekeeping practices were also found deficient, as high-touch surfaces such as handrails were not consistently documented as being disinfected according to the facility's COVID-19 Mitigation Plan, which requires cleaning at least every four hours. The janitor stated that while disinfection occurred twice per shift, there was no log or documented evidence to verify this. The Director of Nursing was unable to confirm the frequency of disinfection or the existence of a tracking log, despite facility policy requiring such documentation. These lapses in infection control practices were observed and confirmed through interviews, record reviews, and direct observation.