Failure to Test Symptomatic Residents for COVID-19: The DON confirmed the facility was not testing all residents with respiratory symptoms for COVID-19 and was relying on physician direction or surveyor request. One resident with dementia, diabetes, and HTN had fatigue, cough, and lethargy before a COVID test was finally obtained; another resident with CAD, HTN, kidney disease, and vascular disease had a prolonged cough, congestion, weakness, and fatigue without evidence of testing; a third resident with severe cognitive impairment, HF, kidney disease, diabetes, and dementia had cough, sore throat, low O2 sat, fever, wheezing, and lethargy before testing was done.
Infection Control Failure With Respiratory Equipment: A resident receiving O2 via nasal cannula had tubing stored in a mesh bag on the concentrator during repeated observations, and the tubing was marked with tape dated 6/8. The facility policy required weekly cleaning and replacement of O2 equipment, but the resident’s order summary did not include the weekly cleaning/change order, and the DON agreed this likely explained why the concentrator was not cleaned and the nasal cannula was not changed per policy.
An LPN and CNA failed to follow hand hygiene and glove-use standards during wound care for a resident with a coccyx wound. They entered the room and donned gloves without hand hygiene, the LPN used a soiled glove to apply Calmoseptine, did not change gloves when moving between soiled and clean tasks, handled soiled garbage with ungloved hands, and left the room without hand hygiene.
An LTC facility failed to follow infection control practices during observed resident care. An LPN administered tube feeding without a gown for a resident with a PEG tube and dysphagia, and staff failed to complete hand hygiene and glove changes during catheter care and wound care for another resident with severe cognitive impairment. An RN also did not perform hand hygiene between glove changes during wound care, and EBP signage was missing from a resident’s door.
The facility failed to complete required communicable disease screening for one new employee and had incomplete screening forms for four other staff members. Staff were observed cleaning reusable bed pans with a vinegar-and-water or spray solution while visible soil remained, a nurse aide providing care had long artificial nails, and oxygen equipment for a resident with COPD and respiratory failure was found unlabeled, undated, or left with another resident’s blue supply bag attached; additional cleaned concentrators in storage also still had used blue bags.
The facility failed to follow infection control measures during care for residents with wounds and indwelling devices. A resident with a chronic wound and EBP needs was transferred, toileted, and received wound care without the required gown use, and wound supplies were handled in a way that included returning an opened item to the treatment cart. Another resident with a urinary catheter and pressure ulcer was assisted with transfer and bathing without a gown, and an LPN treated a resident with multiple wounds by using the same gauze across all sites and not changing gloves between wound areas.
Staff failed to follow hand hygiene and glove practices while assisting residents with meals, including feeding more than one resident at a time, handling food and personal items, and not cleaning hands after removing gloves. Staff also allowed a resident’s urinary catheter drainage bag to remain on the floor and later on the resident’s lap while in the dining area. An LPN and other staff were observed assisting residents without consistent ABHS use between residents.
Hand hygiene was not performed during medication administration for multiple residents. An MA entered resident rooms, handled medications and resident items, donned and removed gloves without cleaning hands, and administered oral meds, creams, and eye drops without hand hygiene between residents. The MA confirmed hands were not being washed during med passes, and the Administrator stated staff frequently lacked readily available hand sanitizer at resident rooms.
Multiple infection control failures were observed, including staff not using PPE correctly for residents on EBP, not performing hand hygiene for the required 20 seconds, and not following clean technique during wound care. Staff also failed to manage catheter care and nebulizer equipment according to policy, with nebulizer chambers left uncleaned, undated, and not stored properly. The IP confirmed there was no surveillance tracking for EBP or transmission-based precautions and no documented review or revision tracking for the infection prevention and control plan.
Improper Disposal of Blood-Contaminated Waste: An LPN discarded a blood-containing glucose test strip and cotton ball into a resident’s trash can after a finger-stick blood sugar check, despite facility policy and device instructions identifying the items as biohazard waste. In a separate event, an RN discarded a syringe containing visible blood after PICC line care into another resident’s trash can; the RN and DON confirmed contaminated waste should not be placed in residents’ trash cans.
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