Infection Control Deficiencies in Laundry and Medication Management
Penalty
Summary
The facility failed to adhere to infection control guidelines in multiple areas, including laundry services, medication preparation, and medication storage. In the laundry area, surveyors observed several deficiencies: dirty linen carts and storage containers were left uncovered or improperly covered, soiled blankets with visible debris were found under machines, and trash containers were not properly lidded. Additionally, a leaking washing machine was managed by placing blankets on the floor, which were replaced only when visibly soiled. Staff interviews revealed uncertainty and inconsistency regarding the requirement to keep dirty laundry covered and the proper handling of soiled items, with some staff unaware of the facility's expectations. In the area of medication preparation and storage, surveyors found open multi-dose insulin vials and insulin pens in medication carts without resident identifiers. Some insulin pens were being used as a substitute for unavailable insulin vials, with staff drawing insulin from the pens using syringes after swabbing the cartridge tops. This practice was described as common by nursing staff, despite facility policy prohibiting the use of multi-dose pens for more than one resident and requiring clear labeling with resident identifiers. Additionally, a cluttered medication cart contained a pill organizer and various medication bottles without proper labeling, and home medications were stored in the cart due to renovations, contrary to policy. Interviews with staff, including the DON and Infection Preventionist, confirmed that these practices did not meet infection control expectations. The DON acknowledged that dirty laundry should be bagged and tied at the source, kept covered, and separated from clean laundry, and that trash cans should be lidded. The DON also stated that insulin pens must be labeled and used only for the assigned resident, and that the observed medication storage practices were not compliant with facility policy. The facility's own policies require strict labeling and storage procedures for medications and biologicals, and prohibit transferring medications between containers or using multi-dose pens for multiple residents.