Infection Control Lapses in Equipment Cleaning, Hand Hygiene, and Labeling of Personal Care Items
Penalty
Summary
The facility failed to implement proper infection prevention and control practices in several instances. The filter of a resident's oxygen concentrator was observed to be dusty, and both the licensed vocational nurse and the infection preventionist consultant confirmed that the filter should be kept clean and cleansed weekly, as per the user manual. Additionally, during medication administration, a licensed vocational nurse did not perform hand hygiene before donning gloves to administer eye drops to a resident, contrary to facility policy. In another instance, a different licensed vocational nurse did not cleanse her hands or change gloves before administering nasal spray to a resident after repositioning him, which was also against facility policy. Furthermore, during room rounds, multiple unlabeled personal care items, including wash basins, bed pans, urinals, and a kidney-shaped basin with a toothbrush and toothpaste, were found in a shared bathroom used by four residents. A certified nursing assistant confirmed that these items were in use and not labeled with resident names or room numbers, increasing the risk of cross-use. The infection preventionist consultant stated that these items should have been labeled before use, in accordance with facility policy requiring all bed pans and urinals to be marked for individual use.