Infection Control Deficiencies in Hand Hygiene, Equipment Cleaning, and Environmental Sanitation
Penalty
Summary
Multiple instances of improper hand hygiene were observed during medication administration for several residents. Staff members failed to perform hand hygiene before entering resident rooms, before and after gloving, and between dirty and clean tasks. In one case, a staff member prepared and administered medications, handled food items, and used a pill cutter without cleaning it or performing hand hygiene at any point. Another staff member applied topical medications and performed personal care tasks without changing gloves or performing hand hygiene between tasks, and then proceeded to prepare medications for another resident without washing hands. Additionally, a staff member washed hands only after leaving the unit and did not perform hand hygiene between contaminated and clean activities. Environmental cleanliness and equipment maintenance were also found lacking. Observations revealed that tube feeding supplies were stored in unsanitary conditions, with bottles showing signs of spoilage and residue present on cupboard surfaces. A suction machine used for a resident had a canister filled with old, crusted liquid, indicating it had not been cleaned after use. Floor mats used for residents were found to be cracked, dirty, and not cleanable, with staff acknowledging the issue but stating it had not been addressed as a priority. A review of facility policies showed that while there was a hand hygiene policy in place, staff education files lacked documentation of hand hygiene training. Furthermore, the facility did not have a policy specific to the maintenance and cleaning of intermittent suction equipment. These deficiencies were identified through direct observation, staff interviews, and record reviews, and were found to have the potential to increase the risk of infection for all residents receiving care.