Infection Control Program Deficiencies: Incomplete Surveillance, Unsecured Treatment Carts, and Unclean Oxygen Equipment
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by incomplete and inaccurate infection surveillance documentation, unsecured treatment carts accessible to residents, and unclean oxygen concentrator filters. The Infection Preventionist (IP) did not ensure that infection surveillance line listings for multiple months included all required information, such as complete symptom listings, culture site and results, and infection clearance status for healthcare-associated infections (HAIs) like skin infections, urinary tract infections (UTIs), and pneumonia. The IP acknowledged that the line listings should be complete and that missing information was not acceptable. Treatment carts on the third floor were repeatedly observed to be left unlocked and unattended, allowing a resident to open drawers and touch items inside without performing hand hygiene. Both housekeeping and CNA staff witnessed the resident accessing the carts but did not intervene or alert nursing staff. The ADON/IP confirmed that treatment carts should always be locked and that residents should not have access to their contents, as this constitutes a breach of infection control protocols and compromises the items inside the carts. Additionally, a resident with chronic obstructive pulmonary disease (COPD) was observed using an oxygen concentrator with a filter that was caked with dust and debris over multiple days. Although there was a physician's order to clean the filter weekly, the filter was visibly dirty, and staff could not confirm when it was last cleaned. The DON stated that oxygen equipment should be clean and follow infection control protocols, but the lack of regular cleaning and documentation led to the deficiency.