Multiple Infection Control Deficiencies Observed
Penalty
Summary
Surveyors observed multiple failures in infection prevention and control practices within the facility. One nurse was seen using a glucometer on multiple residents without properly cleaning and disinfecting it according to manufacturer and facility policy. The nurse wrapped the glucometer in a disinfectant wipe without wiping it down first, and did not ensure the required wet contact time. Additionally, the same nurse failed to disinfect a medication tray between uses for different residents, despite facility policy requiring all reusable items to be cleaned between uses. Another nurse did not wear a gown during enteral tube medication administration, contrary to the facility's Enhanced Barrier Precautions policy, which requires both gloves and gowns for such procedures. Further deficiencies were noted in the handling and storage of resident care equipment. Used nebulizer kits, masks, and tubing were found unlabeled, undated, and improperly stored among residents' personal belongings or in plastic bags on nightstands. Staff interviews revealed inconsistent knowledge of cleaning, labeling, and replacement protocols for these items, with some staff unsure of the correct procedures or frequency of changes. Similar issues were observed with nasal cannulas, which were left uncovered, undated, and not stored in plastic bags when not in use. Used basins were also found unlabeled and stored inappropriately in shared bathrooms, and a bag of soiled towels was left on the floor outside the soiled linen room, both in violation of facility policy. Additional infection control lapses included the absence of Enhanced Barrier Precautions signage for a resident with a stage 3 pressure ulcer, and urinary catheter drainage bags observed touching the floor in two separate resident rooms. Staff confirmed that these practices did not align with facility policies, which require catheter bags to be kept off the floor and signage to be posted for residents requiring enhanced precautions. These observed failures were corroborated by staff interviews and a review of facility policies, all of which outlined proper procedures that were not followed during the survey period.