Failure to Implement Effective Infection Control and Enhanced Barrier Precautions
Penalty
Summary
The deficiency involves the facility’s failure to implement an effective infection prevention and control program, including proper hand hygiene and appropriate use of Enhanced Barrier Precautions (EBP). During observation, a restorative aide removed gloves in one resident’s room, left without performing hand hygiene, crossed the hallway, and entered another resident’s room before later acknowledging that hand hygiene should have been performed after glove removal and between residents. This conduct occurred despite a facility hand hygiene policy requiring staff to perform hand hygiene after each direct resident contact and after removing gloves. Surveyors also reviewed the facility’s infection surveillance line listings for December and January and found that, while no residents were listed with Candida auris (C. auris), there were entries for skin and soft tissue infections. The January listing contained multiple incomplete sections regarding symptoms, whether cultures or testing had been done, and the results of such testing. The December listing included generalized symptoms such as pain, acute functional decline, and urinary tract symptoms, without clear, complete documentation. The Infection Preventionist (IP) reported not tracking or maintaining a list of residents diagnosed with C. auris on the line listing and stated that residents with C. auris should be on EBP indefinitely, but that C. auris cases were not added to the line listing because those residents were not receiving antibiotics. Further observations and record reviews showed that a resident with an active physician order for EBP related to C. auris, IV, and wound care did not have any precaution signage posted on or near the room door. Staff assigned to this resident, including CNAs, reported that there were no precautions in place and believed the resident only had a wound. The IP later confirmed that all residents on the C. auris list should have signs posted and that the resident in question had been readmitted and should have been on precautions at that time. Facility policies on infection prevention and control, transmission-based precautions, and EBP specified that residents colonized or infected with MDROs, including C. auris, require EBP and appropriate isolation measures, but these were not consistently implemented or communicated to staff.
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