Failure to Implement Infection Control Practices and Enhanced Barrier Precautions
Penalty
Summary
Surveyors identified deficiencies in the facility's infection prevention and control program based on observations, interviews, and record reviews involving two residents. For one resident with a history of altered mental status, muscle weakness, and stroke, staff failed to perform proper hand hygiene after providing incontinence care. Specifically, a certified nursing assistant removed soiled briefs and cleansed the resident but did not remove gloves or wash hands before touching multiple surfaces in the resident's room, including clothing, closet, mechanical lift, and wheelchair. The same staff member then wheeled the resident into the dining room and touched the table with contaminated gloves, which was acknowledged as cross-contamination by both the staff member and the Director of Nursing during interviews. For another resident with a left above-knee amputation, muscle weakness, and wounds including a surgical wound and an unstageable pressure ulcer, the facility failed to implement Enhanced Barrier Precautions (EBP) as required. The resident's care plan did not include EBP, and there were no EBP signs or PPE carts near resident rooms. During wound care, staff only donned gloves and did not use gowns, contrary to facility policy and current infection control guidelines. Interviews revealed that staff and the Infection Preventionist were not following updated guidance regarding EBP, and the Director of Nursing later confirmed that the resident should have been on EBP due to the presence of wounds. The facility's policies on hand hygiene and EBP were not consistently followed, as evidenced by staff actions and statements. The lack of proper hand hygiene after incontinence care and the failure to use appropriate PPE during high-contact care for residents with wounds contributed to the deficiencies cited under 10 NYCRR 415.19(a)(1-4)(b)(1-4).