Failure to Maintain Effective Infection Control Practices
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, as evidenced by multiple observed lapses in infection control practices for three residents. For one resident with a history of metabolic encephalopathy, heart failure, candidiasis, chronic kidney disease, and other significant comorbidities, enhanced barrier precautions for Candida auris were not properly implemented. There was no signage on the resident's door indicating enhanced barrier precautions, and staff were observed improperly donning and doffing personal protective equipment (PPE), including failing to sanitize hands before donning gloves, dropping clean gloves on the floor and returning them to a pocket, and not properly cleaning hands after removing PPE. Additionally, a CNA was observed removing a gown incorrectly and not performing hand hygiene after glove removal. For another resident with cerebral palsy, contractures, and a gastrostomy, staff were observed gathering wound care supplies with dirty gloves and placing clean bandages on a contaminated surface before use. During wound care, the nurse did not use proper hand sanitizer after each glove change, and the assisting CNA improperly removed her gown and failed to dispose of it correctly. A third resident, who had acute kidney failure and unstageable pressure ulcers, was subjected to cross-contamination when dirty linen was placed on the bed and clean linen was subsequently placed on top of it. The assisting CNA again improperly removed her gown and handled clean linen after contact with contaminated items. Interviews with staff revealed a lack of awareness and training regarding infection control protocols, particularly for residents with fungal infections or those requiring enhanced precautions. The Housekeeping Manager was unaware of CDC cleaning guidelines for fungal infections and did not receive communication from nursing staff about residents on isolation. The Regional Compliance Nurse and other staff members demonstrated gaps in knowledge about infection control procedures and communication processes. Review of facility policies showed that while general infection control measures were outlined, the wound treatment management policy did not address infection control protocols during wound care.