Failure to Follow Infection Prevention and Control Practices
Penalty
Summary
The facility failed to adhere to infection prevention and control practices for all sampled residents, as evidenced by multiple observed deficiencies. Personal toiletries and resident care items were found unlabeled and improperly stored inside shared restrooms accessible by multiple residents, rather than being labeled and kept at the bedside or in closets as required for infection control. Staff interviews confirmed that these items should have been individually labeled and stored away from communal areas to prevent cross-contamination. Additionally, medical supplies in the medication storage room were found to be expired, and staff personal belongings were improperly stored alongside medical supplies, both of which were acknowledged by staff as violations of infection control protocols. Further deficiencies were observed in the management of enteral feeding supplies. For two residents receiving tube feedings, the water flush bags were not changed within the required 24-hour timeframe, as confirmed by both the infection preventionist and the DON. Observations showed that the bags remained in use beyond the recommended period, increasing the risk of contamination. Facility policy and staff interviews indicated that timely replacement of these bags is essential to prevent bacterial growth and maintain a sanitary environment for residents receiving enteral nutrition. Environmental cleanliness was also compromised when an absorbent brief was observed on the floor near a resident's bed and was not promptly disposed of by multiple staff members who entered the room. Despite several staff noticing the brief, it remained on the floor until a CNA eventually discarded it. Staff interviews confirmed that such items should be immediately removed to maintain a sanitary environment, and the presence of the brief on the floor was recognized as an infection control issue. The facility's infection prevention and control policy requires all staff to maintain cleanliness and address environmental hazards, which was not followed in this instance.