Infection Control and Sanitation Deficiencies
Penalty
Summary
The facility failed to implement proper infection prevention and control measures, particularly concerning respiratory precautions for a resident. Staff members, including registered nurses and licensed practical nurses, incorrectly indicated that the N95 respirator should be removed inside the respiratory precautions room, contrary to guidelines that require it to be removed outside the room. This misunderstanding was confirmed during an interview with a registered nurse who was unaware of the correct procedure. Additionally, the facility's policy on cleaning and preventative maintenance was not adhered to, as evidenced by the presence of soiled linens on the floor in a resident's room. Further observations revealed unsanitary conditions in several residents' bathrooms and living areas. Three residents had commodes with dried brown substances, indicating a lack of proper cleaning. Additionally, floor mats in the rooms of four residents were found to be dirty, with debris and dried food substances present. These findings were confirmed by staff members during tours of the facility. The Director of Nursing acknowledged the facility's failure to implement infection prevention and control monitoring policies effectively.
Plan Of Correction
Facility immediately had toilets in rooms 385, 293 and 284 cleaned and facility immediately removed soiled fall mats and replaced them with clean fall mats on 1/14/2025. Education provided to staff immediately on 1/14/2025 for proper doffing of face masks and respirators between resident rooms and dirty linen on the floor. Staff educator/designee will educate all staff on Infection Control Policy and Procedures. Staff educator/designee will educate all housekeeping staff on cleaning rooms/bathrooms properly and cleaning of the fall mats. Educator/Designee will provide education to nurses' aides regarding dirty linen and fall mats; aides are to stand mats up and lean them up against the wall (only when resident is out of bed) to facilitate thorough cleaning of the equipment by Housekeeping. Baseline whole house audit will be completed for both fall mats and resident bathrooms. Ongoing audits will continue weekly x 4 weeks, bi-weekly x 2 months and monthly x 3. Audits on PPE and dirty linen will occur; 10 random rooms will be checked daily for one week, then 3 times a week x 1 month, then 1 time a week x 1 month. All results will be reported to the QAPI Committee for review.