Infection Control Lapses in Respiratory Equipment Storage, Laundry Handling, Ice Service, and Hand Hygiene
Penalty
Summary
The deficiency involves multiple failures in infection prevention and control practices related to the storage and handling of resident respiratory equipment, clean laundry, and ice service items, as well as inadequate hand hygiene during medication administration. During an initial walk-through, surveyors observed several residents’ nebulizer masks not stored in sanitary containers when not in use: one mask was lying next to an oxygen canister, another on a blue tote by a doorway, another at the bottom of a bed, and another on a bedside table. A resident’s nasal cannula was also found wrapped around the handle of an oxygen canister rather than contained in a sanitary manner. Staff later stated that respiratory equipment should be cleaned and placed in plastic bags when not in use. Surveyors also observed that a green cart containing clean laundry on one hall was uncovered, exposing blue chucks, brown blankets, and white sheets, despite staff statements that such carts should always be covered. In a day room, an ice scoop was found lying directly on a metal cart next to an ice chest instead of being stored in a designated container. Staff interviews confirmed that the ice scoop should have a container or holder and that the clean laundry cart should be covered, indicating a discrepancy between facility expectations and actual practice. In addition, there were repeated lapses in hand hygiene by a nurse during medication passes. The nurse prepared and administered medications to multiple residents in succession without performing hand hygiene after exiting resident rooms, after touching potentially contaminated items such as trash can lids, blankets, her own clothing, and her face, and after doffing gloves. She also handled a resident’s drinking cup, filled it with ice, and returned it to the resident without performing hand hygiene between tasks. The facility’s hand hygiene policy stated that hand hygiene is the primary means to prevent the spread of infections and that personnel should follow handwashing/hand hygiene procedures, but the observed practices did not align with these requirements. The facility did not provide a policy for clean laundry storage when requested.
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