Failure to Implement and Monitor Infection Control and Enhanced Barrier Precautions
Penalty
Summary
The facility failed to establish and implement an effective infection prevention and control program as required by policy and regulation. The Infection Preventionist (IP)/Director of Nursing (DON) did not track infections by specific organisms, nor did they monitor for outbreaks or cross contamination among residents. Documentation reviewed, including the Nosocomial Infection Summary and Line Listing of Patient Infections, lacked information on the specific organisms involved in infections, and the IP/DON confirmed that such tracking was not performed. Additionally, there was no evidence that the facility monitored for cross contamination or investigated potential outbreaks, even when multiple urinary tract infections (UTIs) occurred on the same hallway within a month. For one resident, who had diagnoses including deep tissue damage, osteomyelitis, and malignant neoplasm of the prostate, the facility failed to implement Enhanced Barrier Precautions (EBP) as ordered by the physician. Observations revealed that EBP signage was not posted on the resident's door, and staff did not consistently use the required personal protective equipment (PPE) during wound care. Specifically, staff entered the resident's room, donned gloves but not gowns, and performed wound care without following the EBP protocol, despite being aware that the resident was under EBP. Interviews with staff, including an LPN and the Assistant Director of Nursing (ADON), confirmed that EBP signage should have been present and that both gown and gloves were required for wound care. The lack of signage and failure to use appropriate PPE during high-contact care activities demonstrated a breakdown in the facility's infection control practices, as outlined in their own policies and job descriptions.