Oak Haven Rehab: Infection Control Lapses - FL

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.