Failure to Maintain Infection Control and Safe Sharps Disposal
Penalty
Summary
The facility failed to properly implement and maintain infection prevention and control measures for two out of five residents reviewed. For one resident with a positive C. difficile diagnosis, staff did not use the appropriate germicidal bleach wipes for disinfecting high-contact surfaces, instead relying on alcohol-based hand sanitizer, which is not effective against C. difficile spores. Staff interviews revealed a lack of awareness regarding the correct disinfectant, and the proper supplies were only presented after prompting by the surveyor. Additionally, the facility did not consistently initiate Enhanced Barrier Precautions (EBP) for residents at increased risk of multidrug-resistant organism (MDRO) acquisition, such as those with wounds or indwelling medical devices. For another resident with chronic wounds and a midline catheter, EBP signage and PPE supplies were not in place immediately after the catheter placement and were removed prematurely after the catheter was taken out, despite ongoing risk factors. The facility also failed to adhere to safe sharps disposal practices as required by OSHA and FDA guidelines. A sharps container in a resident bathroom was observed to be overfilled on multiple occasions, and staff confirmed that containers were only replaced when full, rather than when they reached the recommended three-fourths capacity. These lapses in infection control and environmental safety protocols were confirmed through observation, staff interviews, and record review.