The facility failed to follow infection control practices during tray delivery and medication administration. A CNA passed lunch trays between residents without hand hygiene, and an LVN did not perform hand hygiene before, during, or after a medication pass for a resident with hemiplegia, dysphagia, severe cognitive impairment, and a GT. The LVN also did not wear gloves or a protective gown for the resident on EBP and used Clorox wipes on his hands instead of ABHR or soap and water.
An LVN picked up a resident’s call light from the floor and placed it on the bed sheet without cleaning it first. The resident was cognitively intact, had fractures of the right femur and pubis, DM2, and major depressive disorder, and required assistance with toileting, showering, and transfers. The resident could not reach the call light when asked to press it, and the LVN acknowledged the call light should have been cleaned before being placed on the sheet.
A resident with a PICC line had the dressing and Stat-Lock left unchanged beyond the ordered weekly schedule. RN and DON confirmed the dressing had been changed once and should have been changed again the following Friday, but it remained in place during observation, contrary to the physician’s order and facility P&P for central venous catheter care.
Improper Handling of Soiled Linens in Shared Bathroom: A CNA changed soiled linens for a resident on EBP and placed them directly on a bathroom sink shared with another resident. The resident on EBP had an open wound, VRE, and bilateral BKA, while the roommate independently used the same bathroom and had dementia and other chronic conditions. Staff stated soiled linens should not be placed on surfaces, and the ADON acknowledged the sink placement created an infection control risk.
A resident’s floormat was left propped against the side of the bed during a mechanical lift transfer, with the mat touching the bedding. CNA 2 stated he moved the mat off the floor and leaned it against the bed, and the DON acknowledged this was an infection control concern.
Infection control practices were not followed when two unlabeled wash basins were left stacked on the floor in a shared bathroom between two rooms, rather than labeled and kept at a resident’s bedside. The facility also allowed a resident’s urinal to be stored on a nightstand and side table, including one observation where it contained urine and dripped onto the table. Staff and the DON stated these items should be labeled and kept in appropriate holders or bedside areas, and the resident involved had impaired cognition and needed help with toileting and personal hygiene.
Infection Control Lapses With Oxygen Tubing and Unlabeled Personal Care Item: Two residents receiving O2 were observed with nasal cannula tubing on the floor, including one resident with COPD and another with acute respiratory failure with hypoxia. In a shared restroom, an unlabeled perineal and skin cleanser belonging to one resident was stored in the roommate’s niche; the CNA and IP identified it as a personal care item that should be labeled to prevent cross contamination.
Staff Personal Belongings Kept in Resident Room: CNA 1 left a personal lunch bag, and at times a sweater, in a resident’s room and placed the bag on a chair next to the resident’s bed. The resident stated the bag belonged to her nurse, and the DON confirmed staff should use the designated storage area and not keep personal items in resident rooms. The resident had CHF, rhabdomyolysis, and immunodeficiency, and her care plan identified her as at risk for infection.
A resident receiving oxygen via nasal cannula had a sterile water bottle attached to the oxygen concentrator that was not labeled with the open date. The resident had COPD, atelectasis, CHF, and renal dialysis dependence, and staff including an LVN, the IP, and the DON confirmed that oxygen humidification bottles should be dated when opened and changed when due.
Infection surveillance program not fully implemented. The facility’s IPCP policy required outcome surveillance using standard criteria, but the IP stated the process depended on residents being prescribed antimicrobials before McGeer’s Criteria were considered. Review of the monthly surveillance logs showed only residents on antimicrobials were documented, and there was no documentation that residents with signs and/or symptoms of infection who were not prescribed antimicrobials were evaluated for McGeer’s Criteria.
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