Failure to Maintain Infection Control Practices and Policy Review
Penalty
Summary
The facility failed to maintain appropriate infection prevention and control practices as evidenced by multiple observed breaches and lack of policy review. During wound care, an LPN brought a full box of gloves into a resident's room, used gloves from the box, and then removed the same box for use with other residents, despite acknowledging that this practice could create a contamination risk. Additionally, a maintenance assistant exited a room under Contact Precautions for candida auris without wearing required PPE (gown or gloves) and did not perform hand hygiene after leaving the isolation room. The assistant also indicated a lack of knowledge regarding infection prevention protocols and had not received relevant training. Further review revealed that the facility's Infection Prevention and Control Program policy, last revised in October 2018, had not been reviewed or updated annually as required by the facility's own policy. Staff interviews confirmed that all personnel are expected to adhere to PPE and hand hygiene protocols, and that glove boxes used in resident rooms should not be removed to prevent cross-contamination. These failures were identified through observations, staff and resident interviews, and record review.