Infection Control and Prevention Failures in Facility
Penalty
Summary
Surveyors observed multiple failures in infection prevention and control practices within the facility. A Licensed Vocational Nurse (LVN) was seen not performing hand hygiene between tasks, such as moving between resident rooms and handling items like used cups, which was confirmed by the LVN during an interview. Additionally, a licensed nurse did not change gloves between tasks while preparing and administering intravenous medication, a fact acknowledged by the nurse and the Director of Nursing (DON). Equipment used for respiratory therapy was not properly managed. One resident's nasal cannula and nebulizer mask were found undated and not properly stored, with the DON confirming these observations and stating that such items should be stored in a designated bag. Another resident's nasal cannula was undated, the humidifier was outdated, and the oxygen concentrator filter was visibly dusty with an accumulation of whitish-grayish substances. The DON confirmed these findings, and facility policy required regular dating, changing, and cleaning of such equipment. Environmental cleanliness was also lacking, as dark brownish substances were observed on top of the medication storage cabinets in the medication storage room. Both the DON and the housekeeping manager confirmed that the area should have been kept clean, in accordance with facility policy. These observed failures in hand hygiene, glove use, equipment management, and environmental cleanliness were documented through direct observation, interviews, and review of facility policies.