Failure to Implement and Maintain Infection Control Program
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, as evidenced by multiple lapses in staff adherence to infection control protocols. Dietary staff did not change gloves between clean and dirty tasks, and facility staff failed to apply appropriate Personal Protective Equipment (PPE) when providing care and treatment to two residents. Specifically, staff did not don isolation gowns or change gloves and perform hand hygiene between clean and dirty tasks while caring for a resident on enhanced barrier precautions (EBP) due to a surgical wound and a peripherally inserted central catheter (PICC) line. Staff were observed entering the resident's room, applying gloves, and providing peri care without wearing gowns, and one staff member used gloved hands to retrieve items from a drawer without changing gloves or washing hands afterward. Interviews with staff and facility leadership confirmed that the expected protocol was not followed, as staff should have worn gowns and changed gloves with hand hygiene between tasks for residents on EBP. The facility also lacked an effective infection surveillance program, further contributing to the deficiency. The affected resident had a history of surgery, a PICC line for IV antibiotics, and was dependent on staff for all activities of daily living, including care that required strict adherence to infection control measures.