Infection Control Deficiencies in Respiratory Equipment, Shared Items, Linen Storage, and Water Management
Penalty
Summary
Surveyors identified multiple deficiencies in infection prevention and control practices within the facility. Observations revealed that nebulizer machines and equipment for three residents with chronic obstructive pulmonary disease (COPD) were not properly cleaned or stored. The nebulizer masks and tubing were left attached to the machines, uncovered, and with wet medication chambers between uses. In one case, a BiPAP machine mask was found resting in an uncovered basin on the floor, alongside other items, and was not cleaned or stored as required. Staff interviews confirmed that cleaning and storage protocols were not consistently followed, and care plans lacked specific instructions for these procedures. Further deficiencies were observed in the maintenance and use of shared equipment and personal care items. The whirlpool bath chair in the shower/tub room had rusted, cracked, and bubbled surfaces, making it uncleanable. Shared, partially used, and unlabeled personal hygiene products were available for use among residents, contrary to staff expectations that each resident should have their own products to prevent cross-contamination. There was no policy in place regarding the shared use of personal hygiene items, and staff acknowledged the risk of infection control concerns due to these practices. Additional issues were found in the storage of clean linens, where unclean items such as walkers, shoes, personal care items, and opened packages of briefs were stored alongside clean linens in designated linen closets. This practice was contrary to facility policy, which required that only clean linen be stored in these areas to prevent contamination. The facility also lacked a water management plan to assess, prevent, and monitor for Legionella and other waterborne pathogens, with no policies or testing protocols in place.