Infection Control Lapses in Resident Care Items, Oxygen Storage, and Hand Hygiene
Penalty
Summary
The deficiency involves failures in the facility’s infection prevention and control practices related to resident care items, equipment storage, and staff hand hygiene. Surveyors observed multiple unlabeled wash basins in shared resident bathrooms and sinks, including basins on the floor and in sinks, which a CNA confirmed were currently in use for residents. The CNA stated that basins should be labeled with the resident’s name when rooms and bathrooms are shared, should not be left on the floor or in sinks when not in use, and should be cleaned and stored in the resident’s closet after each use. The facility’s infection preventionist (IP) also stated that resident care items, including wash basins, should be labeled with the resident’s name and stored in a plastic bag in the resident’s closet when not in use, consistent with the facility’s policy that single-resident-use items are for single-resident use only and must be labeled with the resident’s name and/or room number. The deficiency also includes improper organization and separation of clean and used oxygen equipment, and failure of housekeeping staff to perform hand hygiene after glove removal. In the oxygen supply storage room, surveyors and an LVN observed a cluttered, unorganized space with multiple free-standing emergency O2 tanks and room air concentrators on the floor, with no designated or labeled areas to distinguish clean from used equipment. The LVN stated they were unable to identify clean from used equipment and that staff should organize and separate these supplies, while the IP stated the room should be clean and organized, with separate areas and signage for clean and used equipment, and clean oxygen equipment stored in plastic bags to protect from dust, in line with facility policy. In a separate observation, a housekeeping staff member removed gloves after exiting a resident room, then touched the housekeeping cart and a personal cell phone and placed the used gloves in a uniform pocket without performing hand hygiene. The housekeeping staff member acknowledged that hands should have been washed after glove removal, and the IP stated that all staff should perform hand hygiene before and after glove use and between tasks, consistent with the facility’s hand hygiene policy requiring hand hygiene after removing gloves.
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