Failure to Maintain Infection Prevention and Control Program
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program over a three-day period, as evidenced by multiple observations of unsanitary conditions and improper infection control practices. Surveyors observed dried blood and stool on a commode seat used as an elevated toilet seat in a shared bathroom, with additional dried blood droplets on the floor leading to the sink. Unlabeled and soiled bed pans were left exposed in shared bathrooms, and soiled linen bed chucks were found on the floors of resident rooms. A hole in the shower floor created an uncleanable surface, and blood was observed on a resident's bed frame. These findings were confirmed by interviews with nursing staff, who acknowledged that bed pans should be labeled, sanitized, and stored properly, and that soiled items should not be left exposed or on the floor. Further deficiencies included improper glove use and hand hygiene by a CNA, who handled clean resident clothing and personal items while still wearing soiled gloves after providing peri care. Opened dressing wrappers were found on a resident's blankets, and a resident was observed self-propelling in a wheelchair with a Foley bag dragging on the floor. These observations were confirmed by staff, including the DON, who acknowledged the presence of blood on equipment and uncleanable surfaces. The repeated nature of these findings over several days demonstrates a lack of adherence to established infection control protocols.