Infection Control and Food Safety Lapses Involving Wound Care, Ice Machines, and Personal Refrigerators
Penalty
Summary
The deficiency involves multiple failures in the facility’s infection prevention and control practices and food safety monitoring. For one resident with a stage four pressure ulcer, two LPNs performed a wound dressing change without wearing gowns, despite facility policy and a physician’s order for Enhanced Barrier Precautions (EBP) related to the presence of a wound and a catheter. During this dressing change, the resident, who had diagnoses including peripheral vascular disease, heart failure, and diabetes, was noted to have a cloth underpad on the bed that was soiled with wound drainage. After the dressing change was completed, the resident was rolled back onto the soiled underpad, and one LPN did not perform hand hygiene after removing soiled gloves before donning clean gloves. The Nursing Home Administrator and Director of Nursing confirmed that infection control practices were not maintained during this wound care. The facility also failed to maintain two ice machines in a sanitary manner. Policy required that ice machines and ice storage/distribution containers be used and maintained to assure a safe sanitary supply of ice. Observations of the A/E and B/C pantries showed each ice machine drainpipe coiled directly into the drain without an air gap, and used small heaters, paper towels, gloves, and wash basins stored underneath the ice machines. Debris such as gloves, paper towels, and dust was present within and around the drain and ice machine drainpipe. The Maintenance Director confirmed that the facility failed to maintain both ice machines in a sanitary condition. Additional deficiencies were identified in monitoring personal refrigerator temperatures and adherence to EBP. Two residents with diagnoses including heart failure, anxiety, depression, atrial fibrillation, and high blood pressure had personal refrigerators in their rooms, but the temperature logs for both refrigerators were last documented in October 2025, indicating the facility failed to properly monitor these temperatures. For another resident with a history of MDRO and a wound, a physician’s order required EBP every shift. During morning care that included personal hygiene, brief change, and dressing, a nurse aide provided high-contact care without wearing a gown. The nurse aide stated that staff did not have to wear a gown despite the EBP sign on the door, while the Infection Preventionist confirmed the resident was currently on EBP and required a gown during high-contact care activities.
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