Infection Control Lapses in Meal Service, Laundry, and Sharps Management
Penalty
Summary
Surveyors observed multiple failures in the facility's infection prevention and control program. Meal carts on two separate floors were left open and unattended, exposing unused food trays in foam containers to the environment. Staff were seen delivering meal trays to residents without offering hand hygiene prior to meals in one hallway and two dining rooms. Additionally, eating utensils were left open to the environment and unattended while staff passed meal trays. The facility's hand hygiene policy did not address providing residents with hand hygiene before meals. In the laundry room, several infection control lapses were noted. A personal cell phone was found on the table used for folding linens, and the wall air conditioning unit and a floor fan, both in use, were covered in dust. One dryer was not working and was being used to store clean clothes, while the vents under other dryers contained lint. The area around the washers was dirty, with water stains, a soiled blanket on the floor, and uncleanable porous foam tubes with crusty substances on one washer. Staff interviews confirmed that some of these issues had been ongoing and that cleaning practices were not consistently effective. A resident receiving dialysis was observed with a red-stained towel under the left upper arm, reportedly from a bleeding dialysis site, and had long, dirty fingernails. The resident stated that staff did not offer hand hygiene before meals. Additionally, a sharps container attached to a treatment cart was found to be overfilled, with syringes sticking out above the fill line, contrary to the container's labeling. These findings were supported by photographic evidence and were not in accordance with the facility's infection prevention and control policy.