ELLSWORTH, MN - Federal inspectors documented multiple safety and quality assurance violations at Parkview Manor Nursing Home during a June 2024 inspection, including improper disinfection of therapeutic whirlpool tubs and inadequate staff training programs.
Whirlpool Disinfection Violations Put Residents at Risk
The most significant safety concern involved the facility's failure to properly clean and disinfect whirlpool tubs used for resident bathing. Inspectors observed two nursing assistants who did not follow manufacturer guidelines for the specialized equipment.
During observations, nursing assistant NA-B sprayed the whirlpool with a general cleaning solution and waited only one minute before activating the system's disinfection cycle. According to the equipment manufacturer's posted guidelines, staff should allow disinfectant solution to remain on surfaces for 10 minutes to ensure proper sanitization.
The nursing assistant was also unaware whether actual disinfecting solution was flowing through the jets during the cleaning cycle. Maintenance staff later confirmed that the facility's disinfection solution supply had been empty since 2023, meaning only water was coming through the jets when staff activated the disinfect function.
Equipment Access Problems Compromised Safety Procedures
The facility's infection control problems stemmed partly from a maintenance issue that had persisted for eight years. In 2016, staff installed a water heater that blocked access to the whirlpool's disinfectant solution compartment, making it impossible to refill the automated cleaning system as designed by the manufacturer.
Instead of using the equipment's intended disinfection method, staff resorted to spraying general-purpose cleaners like Triforce and Clorox Fuzion directly onto tub surfaces. However, these products require different application methods and contact times than the manufacturer's specified cleaning agents.
A BETCO specialist consulted during the inspection confirmed that the Triforce solution required three minutes of contact time on dry surfaces and should not be rinsed with water after application. The product was not specifically designed for whirlpool systems and could not guarantee coverage of all surfaces around the jets.
Staff Training and Competency Deficiencies
Inspectors identified systemic problems with staff education and skill verification throughout the facility. The director of nursing acknowledged that department heads had not received annual evaluations and that nursing staff had not completed competency assessments.
During interviews, nursing assistant NA-A reported receiving only online training without hands-on skills demonstrations or competency verification. The director of nursing confirmed she had not conducted skills training with nursing staff beyond annual mechanical lift training provided by outside vendors.
The facility assessment identified multiple areas where staff competencies were necessary, including infection control procedures, hand hygiene, standard precautions, and proper use of personal protective equipment. However, the facility had not implemented these training requirements.
Personal Protective Equipment Violations
Both nursing assistants observed cleaning the whirlpool tub failed to wear required personal protective equipment during the disinfection process. Staff worked with strong chemical solutions without gloves, gowns, or eye protection, despite product labels indicating these safety measures were necessary.
The Triforce disinfectant used by staff specifically requires gloves and eye protection due to its chemical composition. One nursing assistant reported that the solution created an "overpowering" and "irritating" smell during use, indicating potentially harmful exposure.
Quality Assurance Program Shortcomings
Federal regulations require nursing homes to maintain robust quality assurance and performance improvement (QAPI) programs to identify and address care quality issues. Inspectors found that Parkview Manor's QAPI committee was not analyzing data or setting measurable goals for improvement.
The facility had not initiated any Performance Improvement Projects (PIPs) to address high-risk areas of concern. The director of nursing acknowledged that the administrator had chosen not to participate in PIP projects, despite their importance for maintaining high care standards.
QAPI meeting minutes from June 2024 showed no documentation of facility goals, data analysis, or action plans for addressing identified problems. The facility's QAPI policy lacked specific guidance for goal-setting, data analysis, or compliance monitoring.
Medical Implications of Improper Disinfection
Whirlpool tubs in healthcare settings require stringent cleaning protocols because warm water and jet systems can harbor dangerous bacteria if not properly maintained. Legionella, Pseudomonas, and other waterborne pathogens can multiply rapidly in inadequately disinfected systems, particularly in warm, moist environments.
Elderly nursing home residents face heightened infection risks due to compromised immune systems and underlying health conditions. Exposure to contaminated water through inadequately cleaned therapeutic equipment could lead to serious respiratory infections, skin infections, or other complications.
The Centers for Disease Control and Prevention emphasizes that healthcare facilities must follow manufacturer specifications for cleaning medical equipment to prevent healthcare-associated infections. Substituting unapproved cleaning products or modifying recommended procedures can compromise patient safety.
Regulatory Standards for Equipment Maintenance
Federal nursing home regulations require facilities to maintain equipment according to manufacturer specifications and ensure staff receive proper training on infection control procedures. The standards mandate that facilities conduct regular competency assessments and provide ongoing education to maintain safety standards.
The inspection revealed that Parkview Manor had not updated its facility assessment to reflect current staffing competency needs or equipment maintenance requirements. The administrator reported being unable to locate the previous facility assessment and had to create a new document during the inspection.
Facility Response and Corrective Measures
The director of nursing acknowledged during interviews that the maintenance director planned to relocate the water heater to restore access to the whirlpool's disinfection system. She agreed that staff should wear personal protective equipment during cleaning procedures and that the facility needed better infection control training.
However, the facility continued using substitute cleaning products rather than manufacturer-specified solutions until equipment access could be restored. This interim approach did not address the fundamental compliance issues with proper disinfection procedures and staff safety protocols.
The inspection findings affected all 28 residents at the facility, as the violations indicated broader systemic problems with quality assurance, staff training, and safety protocol implementation. Federal regulations require comprehensive corrective action plans to address these deficiencies and prevent recurrence.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Parkview Manor Nursing Home from 2024-06-26 including all violations, facility responses, and corrective action plans.
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