Infection Control Failures in Water Management, Linen Handling, Laundry Sanitation, and G-Tube Care
Penalty
Summary
The facility failed to implement and maintain an effective infection prevention and control program, as evidenced by several deficiencies in water management, linen handling, laundry sanitation, and resident care. The Maintenance Director confirmed that there was no Water Management Program in place, and the facility did not maintain documentation of water testing or perform routine water system flushing, aside from flushing water heaters. The Administrator acknowledged the absence of a Water Management Program and recognized the expectation for facilities to ensure water safety and maintain supporting documentation. Observations revealed that a clean linen rack was left uncovered and unsupervised in a hallway, contrary to facility policy and staff expectations that clean linen should always be covered to prevent infection. The Housekeeping Director and Administrator both confirmed that this practice was not acceptable and could lead to infection risks. Additionally, the laundry area was found to be in an unsanitary condition, with puddles of water, rust-like stains, excessive dust and debris, dirty resident clothing on the floor, and evidence that washing machine filters were not being cleaned daily as required. Staff interviews confirmed awareness of these issues, but cleaning and maintenance were not consistently performed. For one resident with a gastrostomy tube, the facility failed to provide proper care as ordered by the physician. The resident, who was severely cognitively impaired and dependent on enteral feeding, was observed to have a G-tube site with brown, crusty material and unsecured tape on multiple occasions. Nursing staff confirmed that the site had not been cleansed as required, and the responsible LPN admitted to only sometimes cleaning G-tube sites. The Unit Manager also acknowledged that the G-tube site had not been addressed between observations, despite daily care being ordered.