Infection Control Deficiencies in Food Handling, Environmental Surfaces, and Respiratory Equipment Storage
Penalty
Summary
The facility failed to ensure proper infection control practices in several areas, as observed and reported by surveyors. In one instance, a resident with a history of hemiplegia, muscle weakness, and back pain was found to have a flattened cardboard box placed between the bed frame and mattress to alleviate discomfort from a bar in the bed. The cardboard box, which was not a cleanable surface, had visible food particles and debris on it. Staff interviews confirmed that the box was placed there by maintenance at the resident's request, and both nursing and housekeeping staff were aware of its presence, but did not recognize it as an infection control issue. In the dietary department, a staff member was observed handling food with gloved hands, leaving the area to cough, and returning to food preparation without changing gloves or performing hand hygiene. The same staff member was also seen wiping his face on his sleeve and touching his clothes while wearing gloves, then continuing to handle food. The kitchen manager acknowledged that staff are expected to change gloves and perform hand hygiene when moving between tasks or after touching their face or clothing, and that education on hand hygiene had been provided recently. Additionally, respiratory equipment was not stored according to infection control standards. A nebulizer mask was observed unbagged on a bedside table among personal items, and the nebulizer machine was placed on a cardboard box on the floor. Staff interviews confirmed that respiratory masks should be stored in plastic bags at the bedside when not in use, and that cardboard is not a cleanable surface. The facility did not have a policy regarding the storage of nebulizer masks, and the infection preventionist was not aware of the cardboard use until after the observation.