Multiple Lapses in Infection Control Practices
Penalty
Summary
The facility failed to maintain appropriate infection control practices in several instances, as observed and documented by surveyors. During tracheostomy care for a resident with chronic respiratory failure and severe cognitive impairment, a respiratory therapist used non-sterile gloves instead of sterile gloves while performing suctioning, contrary to both facility policy and physician orders that required aseptic technique. The therapist acknowledged the error, and the Director of Nursing confirmed that this was an unacceptable practice. In another instance, a nurse placed a hand sanitizer bottle back into a plastic bag after wound care without sanitizing the outside of the bottle or the bag, then transported it to a wound care cart in the hallway. This action did not follow proper infection control procedures for handling shared medical supplies. Additionally, two residents' CPAP masks were found improperly stored: one inside a cluttered nightstand drawer with personal items and debris, and another on a dusty chair without protective covering, both in violation of manufacturer guidelines and facility policy for respiratory equipment storage. Further deficiencies included the storage of personal items, such as a staff cell phone, inside a clean linen cart, with staff interviews revealing a lack of awareness or training regarding linen cart contents. There was also an incident where an LPN entered a room under contact precautions for MRSA pneumonia wearing only gloves and no gown, despite signage and facility expectations requiring full PPE. Staff interviews confirmed gaps in training and policy awareness related to both linen cart use and adherence to isolation precautions.