Failure to Maintain Infection Control Practices for Residents on Enhanced Barrier Precautions
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program for two residents who required enhanced barrier precautions due to their medical conditions. For one resident with a tracheostomy and a history of candidiasis, the ADON, who also served as the infection preventionist, did not follow sterile technique during tracheostomy care. The ADON contaminated sterile supplies by handling them with clean, non-sterile gloves, failed to maintain a sterile field, and did not perform hand hygiene between glove changes. Additionally, the ADON improperly removed personal protective equipment, further compromising infection control protocols. Another resident, who had osteomyelitis and a sacral pressure ulcer, did not receive wound care using aseptic technique. During wound care, the ADON placed supplies on a contaminated surface, touched sterile items to soiled materials, and failed to perform hand hygiene between glove changes. The resident was left on a soiled incontinence brief during the procedure, and perineal care was incomplete, with the same gloves used for wound care and handling bed covers after contact with feces. The ADON also failed to use a procedure-in-progress sign and did not follow facility guidelines for privacy and supply handling during treatments. Interviews revealed that the ADON, who was responsible for infection control training and oversight, lacked knowledge of state reporting requirements for communicable diseases and was unfamiliar with the facility's QAPI process. Documentation showed that infection control in-services had not been conducted recently, and no immunizations were administered in the previous month. These failures in infection control practices and program oversight placed all residents at risk for the spread of infections.