Failure to Follow Infection Control Practices for Bed Linens and Nebulizer Equipment
Penalty
Summary
The facility failed to maintain infection control measures for two residents when staff did not follow established policies and procedures. For one resident admitted in January 2026 with diagnoses including unsteadiness in feet and dysphagia, a licensed nurse was observed picking up three pillows from the floor and placing them at the foot of the resident’s bed. The Assistant Director of Nursing confirmed seeing the three pillows on the bed and stated that anything that fell on the floor was considered contaminated and should not have been placed back on the bed, describing such items as soiled or dirty. The facility’s Infection Prevention and Control Committee policy indicated that the committee was to assist in the development and implementation of written policies and procedures for the prevention and control of infections among residents, provide guidelines for a safe and sanitary environment, and review, establish, and monitor environmental infection prevention and control practices in accordance with CDC, HICPAC, OSHA, and local and state requirements. For another resident admitted in December 2022 with COPD and emphysema and an order for nebulized medication every eight hours, the nebulizer mouthpiece was observed resting on top of the bedside dresser, not stored in a container or bag to protect it from cross contamination, and placed near a soda and a used drinking cup. The resident stated that staff administered the nebulizer medication but rarely kept the mouthpiece inside the provided plastic bag. A licensed nurse verified that the mouthpiece was not kept inside the plastic bag as required by facility policy and stated that after use, the mouthpiece should be stored in the bag. The Director of Nursing also verified that the mouthpiece was not in the plastic bag and was on the bedside dresser, and stated this practice was not acceptable. The facility’s policy on administering medications through a small volume handheld nebulizer required that the nebulizer equipment be rinsed and disinfected according to facility protocol and stored in a plastic bag labeled with the resident’s name and date.
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