Failure to Implement Infection Prevention and Control Program
Penalty
Summary
The facility failed to implement its infection prevention and control program as required, specifically regarding Enhanced Barrier Precautions (EBP) and proper cleaning protocols. Observations revealed that staff did not consistently use gowns and gloves during high-contact care activities for residents who were either colonized or infected with multidrug resistant organisms (MDROs), had wounds, or had indwelling medical devices. For example, during toileting assistance for one resident and catheter care for another, staff either omitted the use of gowns or failed to perform hand hygiene at appropriate intervals. In several instances, staff were unaware of residents' EBP status or did not follow the policy for donning personal protective equipment during high-contact care. Additionally, the facility did not ensure proper cleaning and storage of resident care equipment, such as CPAP machines. Multiple observations showed a resident's CPAP mask and tubing left on the floor or improperly stored, and staff confirmed that cleaning was not performed according to facility policy or CDC guidelines. This failure to clean and store equipment as required increased the risk of cross-contamination and infection. Hand hygiene practices were also not consistently followed. Staff were observed failing to perform hand hygiene before and after glove use, after removing gloves, and between clean and soiled tasks. These lapses occurred during wound care, catheter care, and incontinent care for multiple residents. Interviews with staff and the infection preventionist confirmed that these practices were not in line with facility policy, which requires hand hygiene at specific intervals during resident care.