Infection Control Lapses in Catheter, Respiratory, Medication, and Linen Handling
Penalty
Summary
The facility failed to implement proper infection prevention and control practices in several areas, as observed through staff interviews, medical record reviews, and policy reviews. For one resident with a Foley catheter, the catheter bag was found on the floor and uncovered while the resident was in bed, contrary to facility policy requiring the bag to be secured below the bladder and covered. Another resident diagnosed with pneumonia and later a UTI was reportedly exposed to staff moving between ill residents without appropriate infection control measures, as described by the resident's representative and confirmed by the DON that there were multiple cases of respiratory illness in the facility during that period. Additional deficiencies were observed in respiratory care, where two residents' oxygen tubing and nasal cannulas were improperly stored, left balled up or touching equipment instead of being placed in designated storage bags as per policy. During medication administration, an LPN handled medications with gloved hands that had touched other surfaces, without changing gloves or performing hand hygiene, before administering the medications. Furthermore, a staff member was seen transporting unbagged soiled linen in her ungloved hand across the hall, which was inconsistent with facility policy requiring soiled linen to be bagged and handled with gloves when removed from resident rooms.