Multiple Failures in Infection Prevention and Control Practices
Penalty
Summary
The facility failed to adhere to current infection prevention and control standards in multiple areas, as observed through staff actions and record reviews. Staff did not consistently follow proper hand hygiene protocols before and after glove use, particularly during blood glucose monitoring procedures. In several instances, staff used alcohol wipes instead of EPA-registered disinfectant wipes to clean glucometers, did not disinfect devices according to manufacturer instructions, and placed glucometers directly on surfaces without barriers. Additionally, staff failed to remove soiled gloves and perform hand hygiene after procedures involving blood, and did not always discard blood-filled test strips immediately after use. The facility did not implement or follow a comprehensive water management program to control Legionella risk. Despite receiving laboratory results indicating high levels of Legionella pneumophila in multiple water samples, the facility did not retest water samples as required, nor did it document corrective actions or maintain records of flushing and descaling faucets, monitoring chlorine levels, or inspecting backflow prevention devices. Residents diagnosed with pneumonia were not tested for Legionella, contrary to facility policy and CDC recommendations. Maintenance staff lacked training and documentation for water testing and were not fully integrated into the infection control committee or water management processes. Infection control practices for Enhanced Barrier Precautions (EBP) were not followed for residents with indwelling devices such as urinary catheters. Staff did not wear required personal protective equipment (PPE), such as gowns and gloves, during high-contact care activities for these residents. Catheter bags and tubing were observed lying directly on the floor, and staff were unaware of the need for EBP in these situations despite prior education. Additionally, oxygen tubing was not properly stored when not in use for one resident. These failures were observed across multiple residents and care situations, indicating systemic lapses in infection prevention and control.