Infection Control Failures in Personal Care, Equipment Cleaning, and Staff Practices
Penalty
Summary
Surveyors identified multiple failures in infection prevention and control practices within the facility. Personal care products such as antifungal powder, barrier cream, lotions, and wet wipes were found in a shared resident bathroom without labels to indicate ownership, and incontinence briefs were stored uncovered near the toilet, increasing the risk of contamination. Staff interviews confirmed that personal care products were not consistently labeled and that shared items, such as wipes, were not always used for a single resident. Additionally, expired products and unlabeled items were found in the soiled utility room, storage room, and salon, with some care equipment stored under sinks, exposing them to potential contamination from plumbing leaks. Staff were observed failing to perform proper hand hygiene and glove use during resident care and medication administration. Certified nursing assistants, medication aides, and nurses did not consistently wash hands before donning gloves, between glove changes, or after removing gloves, despite facility policy requiring these actions. Staff were also seen administering medications, including eye drops and insulin, without performing hand hygiene at required times, and sometimes touched residents' eyes with medication applicators, contrary to policy. Contact precautions were not consistently followed for residents with infections, as staff failed to don appropriate personal protective equipment or perform hand hygiene as required by the facility's protocols. Mechanical lifts and slings used for resident transfers were not cleaned and sanitized between uses, despite being used for multiple residents. Staff interviews revealed a lack of awareness or adherence to cleaning protocols for this equipment. In the salon, used makeup and hair styling tools were not labeled for individual resident use, and the salon chair and equipment were found to be in unsanitary condition, with visible dirt, rust, and residue. The infection preventionist acknowledged the risks associated with improper storage and expired supplies, and staff interviews confirmed gaps in knowledge and practice regarding infection control policies.