Infection Control Failures in Supply Storage, Oxygen Equipment, and Enhanced Barrier Precautions
Penalty
Summary
Facility staff failed to implement effective infection prevention and control measures, resulting in multiple deficiencies. On the second floor, which was unoccupied by residents, surveyors observed 65 boxes of incontinent products, disinfectant cleaner, and other resident care supplies stored in rooms with missing ceiling tiles and visible black spots, which staff identified as mold. Additional observations in the therapy gym and office revealed discolored and damaged ceiling tiles, missing plaster exposing brick, and further black spots attributed to water damage from a leaking roof. Despite management and ownership being notified of the water damage, no repairs had been completed since the initial report, and there was no current plan to address the ongoing leaks or mold-like spots. For one resident, staff failed to follow physician orders and facility policy regarding oxygen tubing changes. The resident's treatment administration record required weekly changes of oxygen tubing, with proper labeling and cleaning of the concentrator. However, observations over several days showed the tubing was not changed as ordered, with dates on the tubing indicating it had not been replaced for at least eight days. The DON confirmed the tubing had not been changed and that the documentation was invalid, indicating a lapse in infection control practices related to respiratory equipment. In another case, staff did not adhere to enhanced barrier precautions for a resident with severe cognitive impairment, an indwelling medical device, and an order for contact precautions due to MRSA. During a transfer from a recliner to a wheelchair and then to bed, staff did not wear the required PPE, only donning gown and gloves after the transfer was completed. Interviews with staff confirmed that they were aware of the need for PPE during high-contact activities but failed to implement these precautions during the observed transfer.