Infection Control Lapses in Storage, Wound Care, and PPE Use
Penalty
Summary
Surveyors identified multiple infection control deficiencies within the facility. During an environmental tour, urinals, bedpans, and wash basins were observed improperly stored in shared bathrooms, including being hung from grab bars or placed on the floor, and not contained in plastic bags as required by facility policy. These items were accessible in areas shared by two residents per bathroom. The facility's policy specified that such items should be stored in a resident's bedside cabinet or drawer after being placed in a plastic bag, but this was not followed. Additionally, during wound care for a resident with pressure ulcers, an RN failed to change gloves between treating different wound sites and after providing incontinence care, despite facility policy requiring glove changes between each dressing change and after removing soiled dressings. The RN also placed linen and heel boots on the floor during the procedure. In a separate incident, another RN administered IV medication to a resident on Enhanced Barrier Precautions without donning an isolation gown, as required by both signage and facility policy. These lapses were confirmed through interviews with facility leadership and staff.