Multiple Infection Control Failures in Facility Equipment, Laundry, and Water Management
Penalty
Summary
The facility failed to maintain infection control standards in multiple areas, as evidenced by direct observations and staff interviews. One incident involved a resident's suctioning machine, which was found with a half-full canister of a clear/yellow thick substance and an uncovered cord exposed to the environment. The responsible RN confirmed the machine had not been cleaned or covered after use and had not noticed its condition prior to the observation. Additionally, several resident-assigned wheelchairs and a geri-chair in a hallway were observed with cracks and tears in the arm pads, exposing the inner padding. The facility's Infection Preventionist acknowledged these as infection control issues. The laundry room's ventilation system, designed to maintain negative pressure and prevent cross-contamination between dirty and clean laundry areas, was found to be inoperable for over a month. The air conditioning unit in the clean laundry room was also not functioning. Housekeeping staff and the Regional Director of Maintenance confirmed the ongoing issues with the ventilation system. Furthermore, soiled linen and trash were not removed from shower rooms between uses, and the shower rooms were noted to be humid, musty, and had visible black substance on the walls, which was confirmed by maintenance staff during inspection. The facility also failed to implement proper infection control protocols when using the facility's transport van to carry soiled linen to an offsite laundromat. The van was used to transport soiled linen and then residents, without any arrangements for cleaning or disinfecting the van between uses. The Infection Preventionist was unaware of this practice. Additionally, the facility did not maintain adequate infection surveillance or implement water management protocols, such as flushing and draining dead legs or fixtures in unoccupied rooms. Maintenance and administrative staff confirmed the absence of logs or documentation for these activities, and unoccupied rooms were not properly maintained during periods of vacancy.