Infection Control Failures in Shower Room and Respiratory Equipment Storage
Penalty
Summary
Staff failed to maintain proper infection prevention and control practices in the facility's shower rooms and in the storage of respiratory equipment. Observations revealed that used towels were discarded on the shower room floor, and large bottles of shower supplies and hairbrushes were not designated for individual resident use. Multiple staff interviews confirmed that unlabeled personal care items were used by multiple residents, and staff were unsure of the ownership of certain items. Both the Director of Nursing and the Administrator acknowledged that each resident was expected to have their own labeled bath supplies, and that sharing such items posed an infection control concern. Additionally, the facility did not ensure proper storage of respiratory equipment for two residents with significant respiratory needs. One resident, in a persistent vegetative state with a tracheostomy and chronic respiratory failure, had a nebulizer machine and accessories left uncovered on the over-bed table between uses, rather than being stored in a plastic bag as required. Staff interviews confirmed knowledge of the correct storage procedure, but it was not followed due to oversight. The Director of Nursing and Administrator both stated that respiratory equipment should be covered when not in use. Another resident with COPD, asthma, and obstructive sleep apnea used a CPAP machine, but the CPAP mask was repeatedly observed lying uncovered on the resident's dresser rather than being stored in a plastic bag. Staff interviews confirmed that CPAP masks were expected to be stored in bags, but the facility did not have a formal policy for this practice. The Director of Nursing and Administrator both stated their expectation for proper storage, but this was not consistently implemented.