Failure to Maintain Sanitary Resident Care Equipment
Penalty
Summary
During an unannounced complaint investigation, surveyors observed that devices used for resident care were not maintained in a sanitary condition. Specifically, a pill crusher located on top of a medication cart was found coated with a brown, semi-soft, sticky substance in the area where pills are placed for crushing. This device was used for 15 out of 27 residents who required their medications to be crushed. Additionally, a stand lift machine (EZ-Up brand) used to assist a resident in standing was observed to have crumbs and white and beige colored flakes, including what appeared to be food debris and skin flakes, on the area where residents' feet are placed. Interviews with facility staff revealed uncertainty and inconsistency regarding responsibility for cleaning these devices. The LVN acknowledged the pill crusher had not been wiped down and should be cleaned before use, and expressed concern about the cleanliness of the stand lift machine, noting it looked dirty and needed cleaning. The administrator also observed the unclean equipment and stated that nurses should clean the pill crusher while housekeeping should clean the stand lift, but admitted there was a lack of clarity about who was responsible for cleaning equipment between uses. Review of facility policies confirmed requirements for cleaning and disinfecting environmental surfaces and maintaining an infection prevention and control program, but these were not followed in practice.