Failure to Maintain Effective Infection Prevention and Control Practices
Penalty
Summary
The deficiency involves the facility’s failure to maintain an effective infection prevention and control program, including improper use of PPE, inadequate hand hygiene practices, and noncompliance with transmission-based precautions. Surveyors observed an activities assistant entering the room of a resident on droplet precautions, with COVID-19 signage and a red stop sign on the door, without wearing any PPE, while other staff in the room were properly donned. The assistant initially stated the resident did not “have anything” and had been going to the dining room without a mask, and only acknowledged the need for PPE after being informed the resident had COVID-19. During meal tray delivery and setup on one hall, the admissions coordinator and another employee did not offer or provide hand sanitizer or other hand hygiene to multiple residents before meals and later acknowledged they had failed to do so. In the dining room, another employee was observed carrying a resident’s plate with his thumb resting inside the plate’s food barrier and admitted his thumb was too far into the plate. Additional deficiencies were identified related to environmental controls and adherence to the facility’s own infection control policies. The facility’s exhaust system policy required monthly inspection of laundry room exhaust fans and verification that airflow was sufficient to hold a piece of paper to the vent; however, during a tissue test in the laundry area, air was not pulling from the clean side to the soiled side as required. The facility’s Special Contact and Droplet Precautions policy required doors of affected residents to remain closed, yet multiple doors to COVID-positive resident rooms were observed open on two halls during the survey, and two COVID-positive room doors were later observed open again, with one nurse reporting that the resident leaves the room wearing a mask. The same policy required staff to wear appropriate PPE, including N95 respirator, gown, gloves, and recommended eye protection for encounters with positive patients, but an occupational therapist was observed inside a COVID-positive resident’s room without any eye protection and stated they did not have a face shield or glasses.
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