Failure to Maintain Sanitary Whirlpool Practices for Residents with Open Wounds
Penalty
Summary
The facility failed to maintain a sanitary environment and prevent the transmission of communicable diseases and infections for four residents who were reviewed for infection control. Certified Nursing Assistant (CNA) staff did not clean the whirlpool according to the manufacturer's guidelines, and the facility's policy and procedure for whirlpool cleaning did not align with these guidelines. Observations revealed that the whirlpool's disinfectant jets were not functioning, the disinfectant reservoir was empty, and the cleaning process did not include the use of a brush or proper attention to the swivel lift chair. The CNA responsible for cleaning the whirlpool was unaware of the location of the disinfectant reservoir and did not report the malfunction to her supervisor. All four residents involved had open wounds and were receiving antibiotics for wound infections. These residents continued to receive whirlpool baths three times a week despite their open wounds and ongoing infections. Medical records and interviews confirmed that each resident had a documented wound infection, with cultures showing the presence of various pathogens, including MRSA, Pseudomonas aeruginosa, and Vancomycin-resistant Enterococcus. The residents' wounds were actively being treated with antibiotics as ordered by their physicians. Interviews with facility staff, including the CNA, the wound care LPN/infection preventionist, the maintenance supervisor, and the Director of Nursing (DON), confirmed that the whirlpool was not being cleaned per manufacturer guidelines and that the facility's policy did not require such cleaning. The maintenance supervisor had not been checking the disinfectant reservoir, and the DON had not monitored the cleaning process since assuming her role. The DON acknowledged that residents with open wounds should not have been using the whirlpool and that the current cleaning procedures were inadequate to prevent the spread of infections.