Infection Control Lapses in Resident Care and Food Preparation
Penalty
Summary
Multiple infection control deficiencies were identified during observations, interviews, and record reviews within the facility. Used and uncovered urinals were found on bedside tables next to medical equipment such as spirometers, and suction devices were improperly stored, including a yankauer suction tube placed inside an open clean gloves box and a suction machine and nebulizer covered by a used wash basin. Soiled linens were observed on the floor, and urinals were left full and not emptied in resident rooms. These practices were confirmed by staff, including the assistant director of nursing and certified nursing assistants, who acknowledged that these items should have been stored or disposed of according to facility policy to prevent contamination and cross-infection. Further deficiencies included the lack of enhanced barrier precaution (EBP) signage and personal protective equipment (PPE) outside the room of a resident with a biliary catheter, despite facility policy requiring such measures for residents with indwelling devices. Staff interviews confirmed that EBP signage and PPE should have been present. Additionally, a treatment nurse was observed wearing a surgical mask below the nose during wound care, and two kitchen staff were not wearing their face masks properly while preparing food for the tray line. These lapses were acknowledged by the staff involved and by supervisory personnel, who confirmed that masks should cover both the nose and mouth during resident care and food preparation. Review of facility policies indicated requirements for proper storage and handling of soiled linens, urinals, and PPE use, as well as the need for EBP for residents with wounds or indwelling devices. The observed failures to follow these policies were confirmed by staff during interviews and were directly linked to the deficiencies cited in the report.