AUBURNDALE, FL - Oak Haven Rehab and Nursing Center was cited for multiple infection control violations during state inspections conducted in July and September 2024, including failures to properly secure medication carts and inadequate adherence to isolation precautions designed to prevent the spread of infectious diseases.
Medication Security Breaches Create Safety Risks
During a September 2024 revisit inspection, surveyors discovered three treatment carts left unlocked and unattended near the nurses' station at 9:17 AM. The carts contained prescription medications for resident treatments and remained accessible without any staff supervision. Photographic evidence documented the security breach.
When interviewed, a Licensed Practical Nurse confirmed that treatment carts should never be left unlocked. The Director of Nursing explained that nurses are assigned specific treatment carts that correspond to their medication carts and assignments, with keys provided to authorized personnel including wound care nurses. However, facility policy clearly requires all medication carts to remain locked when not in active use.
This violation poses significant safety risks to residents. Unlocked medication carts can lead to medication errors, drug diversion, or accidental ingestion by confused residents. The Centers for Medicare & Medicaid Services requires facilities to store all drugs and biologicals in locked compartments with access limited only to personnel authorized to prepare and administer medications.
Staff Fail to Follow Isolation Precautions
The facility demonstrated repeated failures in implementing contact and droplet precautions designed to prevent transmission of infectious diseases. Multiple staff members were observed entering isolation rooms without proper personal protective equipment (PPE) despite clear posted instructions.
In one incident, an Occupational Therapist Assistant entered the room of a resident with a Methicillin-resistant Staphylococcus aureus (MRSA) infection without wearing the required isolation gown and gloves. The resident had physician orders for contact precautions that were clearly posted outside the room. When questioned, the therapist stated a nurse told her PPE wasn't necessary because "the infection was in the resident's urine," despite acknowledging she should have followed the posted signage.
A Registered Nurse and Unit Manager was also observed entering the same MRSA-positive resident's room without donning required PPE while conducting rounds and stocking supplies. Both staff members had recently received facility training on infection control and proper PPE procedures but failed to implement the protocols.
Contact precautions are specifically designed to prevent transmission of infectious agents through direct or indirect contact with residents or contaminated environmental surfaces. MRSA can survive on surfaces for extended periods and spread to other residents through contaminated hands or equipment, making proper PPE compliance critical for preventing healthcare-associated infections.
Widespread Hand Hygiene and Equipment Cleaning Failures
The July 2024 inspection revealed systemic failures in basic infection control practices during medication administration. Surveyors observed six different residents whose care involved improper hand hygiene and inadequate cleaning of medical equipment.
Multiple nurses were documented failing to perform hand sanitization before and after medication administration, a fundamental infection control requirement. One Licensed Practical Nurse was observed using an uncleaned blood pressure cuff on multiple residents consecutively, placing contaminated equipment directly on medication carts between uses.
Blood glucose monitoring equipment presented particular concerns. During one observation, a nurse placed a blood glucose monitor on a dirty overbed table containing personal items and food, then inadequately disinfected the device afterward. The manufacturer's guidelines require glucose meters used on multiple residents to be thoroughly cleaned and disinfected between each patient to prevent transmission of bloodborne pathogens.
The facility's own policies require staff to follow established infection control procedures including hand washing and antiseptic technique during medication administration. Hand hygiene must be performed before and after direct resident contact, medication administration, and any invasive procedures like finger stick blood sampling.
Medical Implications of Infection Control Failures
These violations create multiple pathways for healthcare-associated infection transmission. Improper hand hygiene is the leading cause of infection spread in healthcare facilities, contributing to urinary tract infections, respiratory infections, and surgical site infections among vulnerable nursing home residents.
Blood glucose monitoring equipment contamination poses risks for bloodborne pathogen transmission including hepatitis B, hepatitis C, and HIV. Even minimal blood contamination on inadequately cleaned devices can transmit infections between residents during routine diabetes monitoring.
MRSA infections are particularly concerning in long-term care facilities where residents often have compromised immune systems and chronic medical conditions. The bacteria can cause serious skin and soft tissue infections, pneumonia, and bloodstream infections with mortality rates significantly higher in elderly populations.
Droplet Precaution Protocol Violations
Two staff members were observed exiting rooms designated for droplet precautions while still wearing face protection that should have been removed before leaving the room. Posted signage clearly instructed staff to "Remove face protection before room exit," but a Licensed Practical Nurse and Certified Nursing Assistant both failed to follow these protocols.
One staff member acknowledged the error, stating "Sorry that was my bad; the face shield should have been taken off before I left the room." The Director of Nursing confirmed that staff should don N95 masks before entering droplet precaution rooms and remove all face protection before exiting to prevent pathogen spread to other areas of the facility.
Droplet precautions prevent transmission of infectious agents spread through respiratory droplets generated by coughing, sneezing, or talking. Wearing contaminated PPE outside isolation rooms can spread respiratory pathogens throughout the facility, potentially exposing other residents and staff.
Additional Issues Identified
Beyond the major violations, inspectors documented several other concerning practices. Medication boxes were inappropriately brought into resident rooms, insulin was left unsecured outside locked medication carts, and medical equipment was inadequately cleaned between residents. The facility's quality assurance program, while present on paper, appeared insufficient to prevent these recurring infection control failures.
The facility had implemented corrective measures following previous survey findings, including weekly medication cart audits and facility-wide education on infection control procedures. However, the September 2024 revisit revealed that improvement efforts focused primarily on medication carts rather than treatment carts, and infection control education had not effectively changed staff behavior regarding PPE compliance and hand hygiene practices.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Oak Haven Rehab and Nursing Center from 2024-07-18 including all violations, facility responses, and corrective action plans.
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