Infection Control and TB Screening Deficiencies
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, as evidenced by multiple deficiencies observed during the survey. Specifically, residents on the 300/400 hallway were provided showers in a room that was not free of potentially infectious debris. Observations and interviews revealed that soiled briefs, linens, and dirty towels were left on the floor and shower chair in the shower room after use. One resident reported encountering these items upon entering the shower room, and another resident confirmed seeing dirty towels on the floor on different occasions. Photographic evidence of the soiled items was presented to facility leadership, who initially expressed disbelief but later acknowledged the issue. Housekeeping staff stated that they were responsible for cleaning the shower after each use and recognized the risk of infection transmission if soiled items were handled without gloves. Additionally, the facility failed to ensure that two residents were properly screened for tuberculosis (TB) prior to or upon admission and annually, as required by facility policy. Record reviews showed that one resident had no documentation of TB screening at admission or within the past year, and another resident, while screened at admission, had not received annual TB screening. The facility's policy mandates TB screening for all admissions and annual follow-up, but this was not consistently implemented. The residents involved had complex medical histories, including diagnoses such as Alzheimer's disease, pressure ulcers, osteomyelitis, respiratory failure, and other chronic conditions. Some residents were cognitively impaired, while others were cognitively intact. The failure to maintain a sanitary shower environment and to conduct required TB screenings directly contravened the facility's own infection control and TB screening policies, as confirmed by record reviews and staff interviews.