Infection Control Lapses and Unsanitary Equipment Identified
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program as evidenced by multiple observed lapses in hand hygiene, improper use of personal protective equipment (PPE), and the presence of unsanitary equipment. During Foley catheter care for a resident on enhanced barrier precautions (EBP), two nurse aides removed their gloves but did not perform hand hygiene or re-glove before continuing care tasks such as adjusting clothing and linens. Both staff members acknowledged this was not their usual practice and attributed the lapse to nervousness. Additionally, ten PPE storage bins were found placed directly on the hallway floor outside rooms of residents on EBP, contrary to facility expectations as confirmed by the Regional Operations Coordinator Registered Nurse. Further observations revealed that three wheelchairs, including those used by two residents and an extra chair in the hallway, had cracks or holes exposing inner padding, making them impossible to sanitize. In one instance, the Assistant Director of Nursing (ADON) assisted with feeding a resident without performing hand hygiene or changing gloves after adjusting the resident's bed and bedside table. The ADON acknowledged this lapse during an interview. The presence of unsanitary wheelchairs and improper hand hygiene practices were confirmed by both the ADON and the Regional Operations Coordinator.