Multiple Lapses in Infection Control and Environmental Cleanliness
Penalty
Summary
The facility failed to implement appropriate infection control practices in several key areas, as observed and documented by surveyors. In one instance, a shower room was found to be unclean, with feces, wound dressings, and a band-aid left on the floor and behind the curtain. Despite policies requiring daily cleaning and frequent visual checks, staff interviews revealed that the cleanliness of the shower room was not maintained, and this lapse was acknowledged by both the Housekeeping Director and the Assistant Director of Nursing as a risk for contamination and infection spread among residents. In the laundry area, two out of three dryer tumblers had torn door seal gaskets that were covered with tape, compromising the dryers' ability to reach and maintain proper temperatures. This issue was not reported to the Housekeeping Director until it was discovered during the survey, despite daily checks being part of the facility's maintenance protocol. The lack of timely reporting and repair of the equipment was recognized by staff as potentially leading to improperly dried linens, which could result in mold growth and increased infection risk. Additional deficiencies were observed in the use of personal protective equipment (PPE) and environmental cleanliness. One LPN failed to don gown and gloves when entering a resident's room under contact isolation for a multidrug-resistant organism, contrary to facility policy and posted signage. Another LPN did not wear a gown while repositioning a resident on Enhanced Barrier Precautions, despite clear orders and care plans requiring this for direct patient care. Furthermore, a shared bathroom trash can used by two residents was found to be dirty, stained, and possibly contaminated with feces, yet was not reported or replaced promptly by staff. These lapses in infection control practices were confirmed through interviews, observations, and review of facility policies.