Failure to Provide Soap Dispenser in Resident Bathroom Creates Infection Control Deficiency
Penalty
Summary
A deficiency was identified when a resident's bathroom was found to be lacking a soap dispenser, with an un-labeled plastic cup containing yellow liquid placed on the sink instead. The resident in question was admitted with Alzheimer's disease and anxiety, was severely cognitively impaired, and fully dependent on staff for all activities of daily living, including hygiene and toileting. The resident was also always incontinent and at risk for developing pressure ulcers. The absence of a soap dispenser was confirmed during an observation and interview, with the resident's family member stating that there had never been soap available in the restroom. Staff interviews revealed that the Certified Nurse Aide (CNA) did not report the missing soap dispenser to the charge nurse as required, and the maintenance team was unaware of the issue, as there was no entry in the maintenance log regarding the missing dispenser. The Infection Preventionist Nurse and Director of Nursing both acknowledged that the lack of a soap dispenser and the use of a cup for soap constituted an infection control problem and a safety issue. Facility policies required regular inspection of resident rooms and bathrooms to ensure all dispensers were functioning, but this was not followed in this instance.