Failure to Implement Infection Prevention and Control Practices
Penalty
Summary
The facility failed to implement appropriate infection prevention and control practices for residents requiring Contact Precautions and Enhanced Barrier Precautions (EBP). Multiple instances were observed where staff did not wear required personal protective equipment (PPE), such as gowns and gloves, when providing care to residents with indwelling devices, wounds, or infections with multidrug-resistant organisms. In several cases, signage indicating the need for isolation or EBP was missing or not updated, and PPE supplies were not readily available outside resident rooms. Staff members were observed entering rooms and providing care without donning appropriate PPE, and some staff expressed uncertainty about which residents required precautions or the correct use of PPE. Specific residents with documented infections or indwelling devices, such as urinary catheters or wounds, were not consistently placed on the appropriate precautions. For example, one resident with a positive urine culture for ESBL E. coli and Providencia stuartii remained in a shared room without consistent use of Contact Isolation by staff, despite ongoing physician orders. Other residents with indwelling catheters or wounds did not have EBP signage posted, and staff did not use gowns and gloves during high-contact care activities, including catheter care and transfers. In some cases, staff were observed using shared equipment, such as vital signs machines, without disinfecting them between residents, and wearing gowns outside resident rooms contrary to protocol. Medication administration practices also failed to meet infection control standards. An LPN was observed preparing and administering insulin without disinfecting vial stoppers, performing hand hygiene, or wearing gloves. The LPN also placed an uncapped syringe in her pocket before administering insulin. Facility policies required hand hygiene before and after medication administration, disinfecting vial tops with alcohol, and proper disposal of needles, but these procedures were not followed. These failures were confirmed by interviews with nursing leadership and staff, who acknowledged the lapses in infection prevention and control practices.