Failure to Maintain Infection Control in Shower Rooms
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program in three shower rooms (A-Hall, B-Hall, and C-Hall), as evidenced by multiple observations of unclean and disorganized conditions. In A-Hall, a leaking shower faucet was observed with water accumulating on discolored floor and wall tiles. In B-Hall, the shower room contained cluttered cabinets with unfolded towels, loose gloves, unsecured brief wipes, open and leaking shaving creams, damp towels and bed sheets, overfilled trashcans with exposed soiled items, and a dirty shoestring on the floor. C-Hall's shower room had a loose wall protector on the floor and a shower chair with a damp towel hanging from it. These conditions were observed to persist throughout the day, with no evidence of cleaning or organization between observations. Interviews with staff revealed a lack of clarity and accountability regarding the cleaning and maintenance of the shower rooms. The Assistant Director of Nursing (ADON) stated that CNAs were responsible for cleaning the shower rooms immediately after use, while housekeeping staff were to check the rooms every 1-2 hours. However, the Housekeeping Supervisor indicated that housekeeping was only responsible for pulling trash, not for disposing of dirty briefs, which was left to the CNAs. Several CNAs admitted to not cleaning the shower rooms after use, and some were unaware of the existence of the Daily Shower Room Check List (DSRCL) meant to document cleaning. The Maintenance Director was not made aware of the leaking faucets until after the survey, despite staff stating the leaks had been ongoing for months. Record reviews showed inconsistencies in documentation, with the DSRCL not being checked off on the day of observation and no times noted for when cleaning was completed. The facility's infection prevention and control policy outlined the need for a coordinated, facility-wide approach to infection control, but the observed practices and staff interviews demonstrated a breakdown in implementation and oversight. The lack of proper cleaning, organization, and maintenance in the shower rooms created conditions that could facilitate the development and transmission of communicable diseases and infections.