Failure to Follow Contact Precautions for C-diff: A resident with C-diff was on Contact Precautions, with PPE available and signage posted at the room entrance. Surveyors observed an LSW in the resident’s room without a gown or gloves, and the RN Mgr stated PPE was only needed if touching items before later correcting the staff member. The facility policy required PPE to be worn before or upon entry for residents on Transmission Based Precautions, including C-diff.
Infection control failures were observed involving EBP, PPE, and urinal handling. A resident with an indwelling catheter and another resident with a catheter had no EBP signage posted, an LPN performed trach care for a resident with chronic respiratory failure and a tracheostomy without face protection, and two unlabeled urinals were found hanging in a shower room.
The facility failed to complete an annual review of its ICP and did not document any update or revision of the program. The IP stated she did not know whether the ICP had been reviewed, and the Administrator confirmed that no annual review had been completed.
The facility failed to implement and support an effective infection prevention and control program when a resident on contact precautions for ESBL in the urine was cared for by an LPN who entered and exited the room to administer medications without donning required PPE, despite posted instructions and available supplies. Staff interviews revealed misunderstanding of when gowns and gloves were required and lack of familiarity with EBP, with a CNA stating the facility does not use EBP and that PPE is not needed if direct care is not provided. Review of the infection control manual showed no written EBP policies, and the DON acknowledged she had assumed EBP were in place but was unaware they were not included in the manual.
The facility failed to ensure its infection prevention and control program included clearly visible entrance signage alerting visitors to an active coronavirus outbreak. The DON informed surveyors of multiple active coronavirus cases on two units and instructed them to wear masks, but when the survey team entered earlier there was no clearly visible outbreak notice at the entrance. A sign requiring all visitors to wear masks was later shown to surveyors on the top of the reception desk, but it was not readily visible upon entry.
The facility failed to maintain its infection prevention and control program when a surveyor observed a soiled bed pan stored on the floor under a resident's bed. An LPN stated that bed pans are reused, washed, bagged, and should not be stored under a resident's bed, and the used bed pan was later observed and confirmed under the bed.
Infection Control Lapse During Wound Care and Soiled Linen Handling: An RN performed wound care for a resident with left leg wounds on Contact precautions for shingles, using a towel under the resident’s leg while the open wounds were in direct contact with it. After the dressing change, the RN placed the unbagged soiled towel on a shared sink counter, carried it with bare hands to the soiled utility room, and later cleaned bandage scissors in the sink without first cleaning the sink counter.
A resident with chronic leg ulcers was not placed on Enhanced Barrier Precautions (EBP) as required by facility policy, despite ongoing wound care orders and a care plan indicating EBP should be followed. Staff interviews revealed confusion about the resident's precaution status, and no EBP signage was posted outside the room.
Surveyors found that slings used for resident transport were improperly stored on the floor and on wall hooks where they touched the floor and a lint-filled garbage can. Additionally, there was a buildup of lint behind the dryer and the laundry room floor was covered with dirt and debris, all of which were confirmed by the Regional Director of Clinical Operations.
A CNA failed to wear a gown while providing care to a resident on Enhanced Barrier Precautions (EBP) due to open wounds and an ileostomy, despite facility policy and posted signage requiring gown and glove use for high-contact care activities.
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