Infection Control Lapses in Catheter Care, Equipment Disinfection, and Food Handling
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by multiple observed lapses in infection control practices involving both staff and residents. Several residents with indwelling urinary catheters were found with their catheter drainage bags resting on the floor, contrary to facility policy and staff training, which require that such bags be kept off the floor to prevent contamination. Staff interviews confirmed awareness of the policy, yet the deficiency persisted, with both cognitively intact and impaired residents affected. Additional deficiencies were observed in the handling and disinfection of shared medical equipment. A physical therapy/occupational therapy assistant used a gait belt on multiple residents without disinfecting it between uses, and a blood pressure cuff was used on a resident and then returned to the medication cart without cleaning. Staff interviews revealed inconsistent knowledge and application of the correct disinfection procedures, with some staff using hand sanitizer instead of the required EPA-registered disinfectant wipes, and others unsure of the policy details. Further infection control breaches included a medication aide pouring medications directly onto an unclean tablecloth without a barrier for a resident to self-administer, and a nurse handling a resident's food without gloves. In the dietary department, a staff member's identification badge was observed resting in a resident's food during meal service. Staff interviews indicated a lack of specific training on badge management during food service and inconsistent adherence to policies regarding food handling and contamination prevention.