Failure to Implement Infection Control Measures
Penalty
Summary
The facility failed to implement effective infection prevention and control measures for its residents, as evidenced by multiple observations and staff interviews. Shared bathrooms used by several residents were found to have dirty toilets and, in one case, a dirty sink. Staff, including a licensed nurse and the Director of Environmental Services, acknowledged that the presence of moldy rings and unclean surfaces indicated the bathrooms had not been cleaned as expected. Facility policy required daily cleaning and disinfection of resident bathrooms, but observations and staff statements confirmed that this standard was not consistently met. In another instance, a licensed nurse did not properly store a used feeding tube syringe for a resident receiving enteral nutrition. After use, the syringe was washed in a shared bathroom sink and left exposed in an open bin on the resident's side table, rather than being placed back in its original packaging or a sealed bag as required by facility policy. Staff interviews confirmed that the syringe should have been stored in a manner that protected it from environmental contamination between uses, in accordance with infection control protocols. Additionally, a licensed nurse was observed failing to perform hand hygiene before and after administering medications to multiple residents during a medication pass. The nurse did not use hand sanitizer or wash hands between resident contacts, despite facility policy and staff expectations that hand hygiene be performed to prevent cross-contamination. The nurse acknowledged this lapse and stated a preference for handwashing over hand sanitizer, but only washed hands once during the observed medication administration for several residents. The Director of Nursing and Infection Preventionists confirmed that proper hand hygiene was expected at all times during medication administration.