Inadequate Hand Hygiene and Incomplete Infection Surveillance During COVID Outbreak
Penalty
Summary
The deficiency involves the facility’s failure to consistently implement infection control standards during medication administration and to maintain an effective infection control surveillance program. During a medication pass, an LPN was observed administering medications to four residents, including residents 9 and 65, without performing hand hygiene before each medication administration for each resident. This practice was inconsistent with the facility’s Medication Administration policy, which requires staff to wash hands prior to administering medications and to follow facility hand hygiene protocols. In an interview, the DON confirmed that nurses are expected to perform hand hygiene before and after each medication administration for each resident. The facility also failed to maintain complete and accurate infection surveillance documentation during a COVID outbreak in October 2025 that affected 13 residents and six staff members. The Infection Control RN produced a Respiratory Surveillance Line List for that period and verbally confirmed that the listed individuals had tested positive for COVID, but the document itself did not specify COVID as the pathogen. The line list contained multiple blank or incomplete fields, including missing dates of specimen collection, unspecified test types marked only as “Other,” missing or “N/A” symptom onset dates, blank symptom documentation columns, and pathogen fields marked as “Other” without specifying the organism. The outbreak symptom resolution dates were blank for all names, and the October 2025 facility infection map did not indicate which residents had COVID. These practices did not align with the facility’s Infection Prevention and Control Program policy, which states that the Infection Preventionist leads surveillance activities and maintains documentation of incidents and findings.
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