Inadequate Infection Control Due to Worn Lounge Chairs
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the presence of two worn-out lounge chairs in the dining/activity room. These chairs, made of imitation leather, were observed to be threadbare with mesh and foam exposed, making them unsanitary and unsuitable for proper cleaning. Resident 51 was seen using these chairs, which were available for resident use despite their deteriorated condition. The Infection Preventionist (IP) confirmed that the chairs could not be sanitized properly due to the exposed mesh fabric. Interviews with facility staff revealed a lack of communication and action regarding the condition of the chairs. The Director of Nurses (DON) acknowledged the need to replace worn furniture to ensure sanitization, while the Maintenance Supervisor (MS) stated that the deterioration of the chairs had not been reported in the maintenance log. The IP admitted awareness of the chairs' condition and their use by multiple residents. A review of the maintenance log showed no requests for repair or replacement of the chairs, and the facility's infection control policy emphasized the importance of maintaining a sanitary environment, which was not upheld in this instance.
Plan Of Correction
How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: The identified lounge chairs in the dining/activity room were removed by the facility's Maintenance Director immediately upon identification of the alleged deficient practice. No residents were found to be affected. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All residents have the potential to be affected by this alleged deficient practice as failure to provide a clean, sanitary environment could potentially spread communicable diseases. The Infection Preventionist (IP) and Maintenance Director did a facility sweep for any equipment that could possibly pose a risk for the spread of communicable diseases, no similar item found. No other residents were found to be affected by the alleged deficient practice. What measures will be put into place or what systemic changes the facility will make to ensure that the deficient practice does not recur: It is the policy of the facility to ensure that a safe and clean environment is provided to the residents and preventative measures are taken to reduce the spread of infections. Inservice was provided to all staff on 03/12/2025 by the IP on the facility policy for infection control with emphasis on the importance of providing a sanitary environment to mitigate the risk for the transmission of communicable diseases. The facility will ensure that all resident equipment is clean, sanitized, and in good working condition daily during manager room rounds. Any issues will be reported to the Administrator/Maintenance Director/Designee. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All residents have the potential to be affected by this alleged deficient practice as failure to provide a clean, sanitary environment could potentially spread communicable diseases. The Infection Preventionist (IP) and Maintenance Director did a facility sweep for any equipment that could possibly pose a risk for the spread of communicable diseases, no similar item found. No other residents were found to be affected by the alleged deficient practice. What measures will be put into place or what systemic changes the facility will make to ensure that the deficient practice does not recur: It is the policy of the facility to ensure that a safe and clean environment is provided to the residents and preventative measures are taken to reduce the spread of infections. Inservice was provided to all staff on 03/12/2025 by the IP on the facility policy for infection control with emphasis on the importance of providing a sanitary environment to mitigate the risk for the transmission of communicable diseases. The facility will ensure that all resident equipment is clean, sanitized, and in good working condition daily during manager room rounds. Any issues will be reported to the Administrator/Maintenance Director/Designee. How the facility plans to monitor its performance to make sure that solutions are sustained: The IP/Designee and/or Maintenance Director will audit all resident equipment weekly for 3 months to ensure that equipment is clean and in good working condition. Findings identified will be presented to the monthly QAPI meeting for 3 months for follow-up and recommendations. The administrator will bring 2567 and POC to the QAPI meeting to discuss and ensure understanding for the next 3 months or until substantial compliance is achieved. Completion Date: 03/12/2025