Infection Control Lapses and Environmental Contamination Identified
Penalty
Summary
Surveyors identified multiple failures in infection prevention and control practices on the second floor of the facility. Observations revealed that essential medical equipment and supply carts, including the code cart, wound care/treatment cart, precaution supply carts, and Hoyer lifts, were covered in white/grey powder and dust, later confirmed to be construction debris. Interviews with nursing and administrative staff acknowledged the presence of dust and debris on these items, as well as on the kitchenette hood, and confirmed that cleaning had not been adequately performed. The CDC notes that environmental disturbances, such as construction dust, can release airborne infections, increasing the risk of healthcare-associated infections. Further deficiencies were observed in the handling and maintenance of resident care equipment. A mattress and pillows in a recently vacated room were found to be stained, worn, and with compromised protective coverings, yet were made up and prepared for a new resident after terminal cleaning. Housekeeping and nursing staff confirmed the compromised condition of the mattress and pillows, and administrative staff acknowledged that such items could not be properly disinfected and should not remain in use. Additionally, an out-of-service medication cart was found to be missing a sharps container, with used needles and lancets left inside, and dust-like debris was noted on other equipment and surfaces. Other infection control lapses included the improper storage of resident-specific ice packs in a kitchenette freezer used for food, as confirmed by nursing and administrative staff, and the failure to label wound and PICC line dressings with the date of last change for a resident who had recently undergone surgery. These findings collectively demonstrate a lack of adherence to established infection control protocols and equipment maintenance policies, as confirmed by staff interviews and facility policy review.