Infection control practices were not maintained during medication administration when an LPN failed to perform hand hygiene before and after key tasks, including accucheck use, and after leaving a resident’s room before passing breakfast trays. Surveyors also found unsanitary conditions in two shower rooms and the laundry room, including overflowing trash, dirty linen on the floor, dirty floors, a dirty linen cart, and a dried brown substance on the laundry room floor.
Infection prevention and control was deficient when surveyors observed a wheelchair with holes in the seat exposing inner padding and a Geri-Chair with rips and tears exposing inner padding. The Infection Preventionist and B Hall Nurse manager confirmed the damaged equipment during the walk-through.
Infection control lapses were identified when a resident’s walker seat cover was torn with exposed padding, resident ice packs were stored in the wrong freezer with personal food items, and multiple sit-to-stand lifts had transfer slings left attached. Staff also observed soiled or damaged Geri chairs, wheelchairs, and dining chairs that were not easily cleanable, and the ADON acknowledged there was no policy for storing slings or for cleaning and storing wheelchairs and Geri chairs.
The facility failed to maintain an effective infection control program when two residents’ urinary catheter drainage bags were observed touching or lying on the floor, and a resident’s granulated cylinder was found on the back of a commode without identifying information or proper storage. Staff confirmed the catheter bags should not be on the floor and that the cylinder was not stored properly.
Hand hygiene was not completed during the dining process. During a dining room observation, an RN served residents without cleaning hands between residents, and a NA and RN passed drinks to each other and then served residents without performing hand hygiene. An LPN confirmed the hand hygiene issues.
Failure to provide hand hygiene during meal passes. Residents on multiple halls did not receive hand washing or sanitizing before lunch, and staff placed hand wipes on trays without assisting residents with physical limitations or informing other residents that the wipes were available.
The facility failed to maintain an infection prevention and control program when infection surveillance was not performed for several months after the IP resigned. During a dressing change for a resident with EBP orders and left foot pressure ulcers, an NA assisting with positioning wore only gloves while her clothing and bare arms contacted the resident and bed linens. Two bedpans were also found in a bathroom between rooms C24 and C26 without bags or labels.
Incorrect Transmission-Based Precautions for Resident with MRSA: The facility failed to maintain an effective infection prevention and control program when a resident with a history of MRSA and active abscesses was placed on EBP instead of contact precautions. The resident had multiple recent antibiotic orders for the abscess, and the IP confirmed the resident should have been on contact precautions for MRSA-related wounds.
IV tubing was found not dated for two residents during survey observations. One resident had an IV line in use without a date, and the DON and unit manager confirmed the omission. Another resident had medication running through an IV line that was not labeled with the date and time, and the nurse removed the set after the medication finished. Facility policy required IV tubing to be labeled with the date, time, and initials and changed every 24 hours.
Failure to provide pre-meal hand hygiene was identified for a resident during a dining room observation. An RN Clinical Lead later confirmed the hand wash had not been performed, despite the facility policy stating staff should assist residents with hand hygiene after toileting and before meals as needed.
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