Infection Control Program Deficiencies and Environmental Hygiene Lapses
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program as evidenced by several deficiencies in policy implementation and environmental hygiene. The water management plan was not updated to reflect the current program management team, with outdated names listed for the Executive Director, Maintenance Director, and Director of Nursing. Interviews with current staff revealed that the individuals listed in the plan no longer worked at the facility, and the current team members were either unaware of their roles or had not participated in relevant meetings. The plan had not been revised during the most recent program review, despite changes in personnel. Environmental observations in the laundry area revealed significant lapses in cleanliness and maintenance. The tops of two commercial dryers were heavily soiled with dust and were located near the sorting area for clean linens, creating a risk of contamination. Additionally, one washing machine was found to be in disrepair, rusty, soiled, and partially falling apart. A linen cart with clean linens was observed covered with a heavily soiled material, further compromising the cleanliness of items intended for resident use. These findings were acknowledged by facility staff during the survey. Infection control practices were also not followed during direct resident care. During medication administration, a registered nurse used blood pressure monitoring equipment to assess a resident's vital signs but failed to disinfect the equipment before returning it to the medication cart. This lapse in protocol was observed by the surveyor and contributed to the overall deficiency in infection prevention and control within the facility.