Unlabeled and Cohorted Personal Care Items in Shared Dementia Unit Bathrooms
Penalty
Summary
Surveyors identified a failure to implement an effective infection prevention and control program related to the storage and labeling of residents’ personal care items in shared bathrooms on a dementia unit. In one shared bathroom used by two cognitively impaired residents with dementia, an unlocked tri-fold mirrored vanity above the sink contained multiple personal care items with no resident identifiers, including an empty bottle of Vashe wound cleanser, after shave gel, shaving cream, perfumed body cream, two denture brushes, and a toothbrush. The Memory Care Director stated that no one currently had wounds and could not explain why the wound cleanser was present. Record review showed one resident had severe cognitive impairment and the other had moderate cognitive impairment and needed assistance with personal care. In another shared bathroom used by three residents, the unlocked vanity contained a roll-on deodorant, partially used toothpaste, lotion, and a toothbrush in a foam cup, all without resident identifiers. One of these residents had diagnoses including schizoaffective disorder, psychotic disorder with delusions, paranoid schizophrenia, dementia with behavioral disturbance, and Alzheimer’s disease with late onset, and was assessed as having moderate cognitive impairment. A third shared bathroom, accessible from the memory care unit’s main dining room and used by two residents with dementia and moderate to severe cognitive impairment, contained an unlocked vanity with unlabeled personal care items including skin repair cream, a toothbrush, baby lotion, cornstarch powder, and four incontinence briefs. During interviews, the Memory Care Director and a CNA confirmed that personal care items should have resident identifiers and were normally stored in shower rooms, residents’ drawers, or closets, and the Administrator reported he could not locate a policy for storage of residents’ personal care items.
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