Infection Control Failures in Enteral Supply Handling and Dining Tray Assembly
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program related to the handling, labeling, and storage of enteral feeding supplies for a resident with a gastrostomy tube. Facility policy required all feeding tube syringes to be stored in a clean area, labeled with the resident’s name and date, cleansed with hot water after use, and disposed of after 24 hours, with reusable supplies also labeled and stored appropriately. For a resident diagnosed with dysphagia and gastrostomy, whose medications and routine water flushes were administered via the gastrostomy tube, surveyors observed a 60 cc piston syringe used for tube flushing lying uncovered and unlabeled on the bedside stand, along with an uncovered, unlabeled graduate and an undated gallon jug of water that was two-thirds full. The bedside table was cluttered with personal items. An LPN acknowledged that the syringe, graduate, and water should be labeled and that the water should be dated when opened, but was unsure when the water had been opened and left it in use. The following day, the same syringe dated the prior day was still present in the graduate, and neither the graduate nor the water container were labeled with the resident’s name or date. The Nursing Home Administrator later confirmed that these items should have been labeled, dated, protected from contamination, and replaced daily. Surveyors also found a deficiency in maintaining a safe, sanitary, and comfortable environment in the dining area. During a meal observation in the Royal Garden Cafe, a resident was seated at a table and being assisted by staff to eat lunch at the same table where staff were assembling meal trays for service. The trays at that table contained a napkin, uncovered silverware, beverages, and a meal ticket. The Food Service Director acknowledged that residents should not be seated at the table where meal trays are assembled. In a subsequent interview, the Nursing Home Administrator and Director of Nursing stated that, to avoid infection control concerns, residents should not be seated at the table where meal trays are being assembled.
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