Multiple Infection Control Failures in Resident Care and Food Service
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by multiple observed deficiencies in resident care and food service practices. For one resident with a urinary catheter, the drainage bag was repeatedly observed being hung on a trash bin and covered with a transparent trashcan liner, rather than being properly secured to the bed or placed in a wash bin as per facility policy. Both the resident and staff confirmed that this improper practice occurred regularly, and the infection preventionist acknowledged it as an infection control concern. Another resident requiring tracheostomy care was subjected to improper sterile technique. A licensed nurse placed sterile supplies on a non-sanitized surface and, after contaminating sterile gloves with secretions and debris during cleaning, used the same gloves to handle sterile suction tubing that was then inserted into the resident's airway. This practice was not in accordance with the facility's standard, which requires strict sterile technique for tracheostomy care. Additional deficiencies included staff failing to implement appropriate droplet precautions for a resident on isolation for parainfluenza, as staff entered the room without required face shields despite clear signage and policy. In another case, enteral feeding tubing was left uncapped and undated at a resident's bedside, and a nurse attempted to use it after wiping with alcohol, contrary to infection control standards. In the kitchen, food service staff were observed handling food without proper glove use, failing to change gloves between tasks, not wearing required hair or beard coverings, and wiping hands on clothing, all in violation of facility protocols and FDA Food Code requirements.