Resident Self-Access to Ice Cooler in Violation of Infection Control Practices
Penalty
Summary
The deficiency involves the facility’s failure to prevent a cognitively impaired resident from independently accessing ice from an ice cooler, contrary to infection control expectations. The resident was an adult woman with epilepsy, Down syndrome, major depressive disorder, and mild intellectual disabilities, and had a BIMS score of 07, indicating severe cognitive impairment. On the observed date, the ADON assisted the resident by opening the lid on her cup, after which the resident walked toward the area near the dining room, poured a can of soda into her cup, and placed the cup and lid on top of the ice cooler. The resident stated she obtained ice for her cup herself, indicating staff did not assist her with getting ice from the cooler. Staff interviews confirmed that this resident sometimes got ice from the cooler on her own and that other residents did not. RN A stated that staff tried to assist the resident with getting ice when they saw her walking around, as she might be going to the cooler, but acknowledged that the resident did sometimes get ice herself. CNA B also indicated that the resident often got her own ice, despite residents not being supposed to do so. The ADON confirmed she had opened the resident’s cup but did not anticipate the resident would go to get ice, and acknowledged that the resident would forget staff instructions to ask for help. Staff, including RN A, CNA B, the DON, and the ADM, all identified that residents were not supposed to get their own ice due to concerns about contamination and infection control, yet the resident was still able to access the ice cooler independently.
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