F0880

D

Failure to Clean and Disinfect Blood-Contaminated Room After Resident Fall

Katy, Texas Survey Completed on 01-08-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to maintain an effective infection prevention and control program when managing blood contamination in a resident room following a fall with head injury. The resident was an older woman with COPD, dementia with mild behavior disturbance, macular degeneration with severe visual impairment, difficulty walking, respiratory failure, and a cognitive communication deficit. Her care plan documented impaired visual function and severe visual impairment, and she had a documented history of multiple falls in December, including unwitnessed and witnessed falls, with the last fall on 12/31 resulting in injury. Her BIMS score had declined from 15 (normal cognition) to 6 (severe cognitive impairment) shortly before the incident. She was moved from one room (Room A) to another (Room B) shortly before the fall.

On 12/31, nursing documentation showed that the resident experienced a change in condition related to a fall, with vital signs recorded and increased confusion and memory loss noted. Later that day, an LVN documented finding the resident on the floor in Room B after an unwitnessed fall, with bruising and active bleeding to the forehead. Pressure was applied, vital signs were obtained, the NP and family were notified, and the resident was transferred to the hospital. The LVN later stated that when she found the resident, her head was bleeding, she was sitting in the middle of the floor, and her oxygen tank was next to her; the LVN hypothesized that the resident could have hit her head on the floor or the wall. The ADONs and DON later acknowledged that any blood left behind from the fall should have been cleaned and disinfected and that leaving blood exposed was an infection control issue.

Subsequent observations and interviews revealed that blood and other contamination remained in Room B and that the room had not been properly cleaned either before the resident’s transfer into the room or after the fall. The resident’s RP reported that when she returned to collect belongings after the resident’s hospital transfer, she found a bloody pillow in the resident’s wheelchair, clothing items in drawers from a previous resident, and fecal matter on the bottom of the other bed, and stated that the room did not appear to have been cleaned prior to the room change. Surveyor observation of Room B found a dark reddish/purple circular spot on the carpet near the closet and a dark red smudge on the wall. When housekeeping staff sprayed and wiped the carpet spot, a reddish-brown tint appeared on the cloth, and the housekeeper stated it could be blood and then affirmed it likely was blood. Photographic evidence submitted by the RP showed a pillow with bright red blood on the pillowcase and pillow, identified by the RP as belonging to the resident. Facility staff, including the Maintenance Director, ADONs, and DON, acknowledged that the substances on the pillow, floor, and wall were blood and that the room should have been deep cleaned and blood properly removed in accordance with infection control policy, but this had not occurred. The facility’s written infection control policy required maintaining a safe, sanitary, and comfortable environment and preventing, detecting, investigating, and controlling infections, which was not followed in this instance.

Additional interviews highlighted process failures related to room readiness and cleaning oversight. The Maintenance Director stated he was informed of new admissions or room transfers via a room readiness group text and that housekeeping was expected to deep clean rooms, including disinfecting mattresses and hard surfaces, before a new resident moved in, with him verifying room readiness. He acknowledged that Room B should have been reviewed for cleanliness. Housekeeping staff described that a deep clean included cleaning the television, remote, disinfecting the mattress, and overall cleaning, and one housekeeper stated that no one checked rooms after she completed cleaning them. Another staff member responsible for floors stated he was supposed to clean the floor in Room B but was pulled to other halls and did not complete the task. ADONs and the DON confirmed that housekeeping was supposed to clean rooms after residents left and that blood-stained items should have been cleaned or disposed of, but in this case, blood remained on the pillow, carpet, and wall in Room B after the resident’s fall and transfer, constituting a failure to implement the facility’s infection control policy and practices.