Unsanitary Kitchen Floor Drain: A kitchen floor drain was observed with a buildup of debris and grime, and the Kitchen Mgr confirmed it was dirty and could spread contamination. The Mgr stated floor cleaning was the responsibility of Maintenance, and the Maint Mgr later confirmed the drain had not been recently cleaned and was not sanitary. The facility policy required strict sanitary conditions in Dietary and Nutrition to prevent food contamination and growth of disease-producing organisms.
Laundry staff were not aware of the PPE available for sorting dirty laundry. During observation, no face shields or goggles were seen in the sorting area, and a laundry aide stated her apron was at home, the gloves were on the wall, and she used reading glasses instead of eye protection. The DON later stated the expectation was that aprons not be taken home and that face shields be available for eye protection, while the facility policy required laundry staff to handle linens to prevent spread of infection.
Infection control failures occurred when staff caring for residents on COVID-related precautions cleaned goggles for only 90 seconds before placing them with clean PPE, and an OT wore a surgical mask instead of an N95 in a resident's room. An LPN also handled a glucometer without a barrier, placed it on a resident's overbed table, and returned it to the med cart drawer without cleaning it first.
A staff member failed to perform hand hygiene while assisting residents in the dining room, including after delivering coffee, touching a resident's chair and table, and helping a resident with salad dressing. The staff member acknowledged hand hygiene should have been done between resident contacts and before meal assistance. The IP stated staff should wash hands between touching residents or any surface, and the facility policy required hand hygiene before and after direct resident contact, after contact with nearby objects, and before and after meal assistance.
A CNA failed to follow EBP during catheter care for a resident with an indwelling urinary catheter by not wearing the required gown, reusing gloves across dirty and clean tasks, and not performing hand hygiene at key points. In a separate event, an LPN failed to follow contact precautions for a resident with bacterial conjunctivitis by entering without a gown, leaving the room with contaminated gloves, and touching the medication cart, creating cross contamination during care.
Infection control practices were not followed for multiple residents. A resident’s urinal was left on the floor next to drinking water, clean linens were transported uncovered, an LPN did not clean a tablet splitter before and after use, and an LPN performing wound care did not complete hand hygiene as required and lacked paper towels in the bathroom. Staff also did not follow EBP for a resident’s G-tube care and did not follow contact precautions for a resident with MRSA when entering the room.
Infection Control Lapse During Medication Administration: An RN administered meds to a resident with diagnoses including cellulitis and constipation, then reached into the resident’s medication cup with a bare hand to remove unwanted Senna Plus tablets before giving the remaining meds. The RN confirmed the action and could not explain the correct process, and the DON stated gloves were expected before removing medication from a cup because of infection control and cross-contamination concerns.
An LPN entered the rooms of two residents with confirmed COVID-19 without the required eye protection, gown, or gloves, despite signage and orders for droplet/contact precautions. During wound care for a resident with a stage IV coccyx pressure ulcer, an RN donned PPE in the wrong order, changed gloves without hand hygiene after cleaning a bowel movement, handled supplies before hand hygiene, and left the room wearing the isolation gown while returning to the wound cart.
Incomplete Water Management Program: The facility failed to maintain an up-to-date, facility-specific WMP to prevent Legionella growth and spread. The WMP included only a brief water path description and a sample CDC diagram, while a current building-specific water system diagram could not be located. The most recent Water Safety Management Assessment & Plan was dated 11/22/2021, and although staff reported Legionella testing, chlorination, and flushing, no recent documentation of those measures was available for review.
PPE use was not followed for residents on contact precautions and EBP. A DON was observed leaving a contact precaution room with gloves on and handling a med cart before returning, a CNA was observed at the bedside of a resident on contact precautions with no PPE, and a staff member was observed providing direct care to a resident on EBP while wearing only gloves. The facility also identified an outbreak of infectious dermatitis affecting multiple residents across several hallways, but despite recognizing it as reportable, the IP did not complete a state outbreak report.
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