TORRANCE, CA - Federal inspectors documented multiple infection control failures at Torrance Care Center West during a July 2024 inspection, including staff failing to wash hands after cleaning spills and residents sharing smoking aprons without proper disinfection.
Hand Hygiene Failures Put Residents at Risk
During the inspection, surveyors observed a certified nursing assistant cleaning a wet substance from the floor at a nursing station, disposing of the paper towel, then proceeding to resident care areas without washing her hands. The incident occurred despite a hand washing sink being available at the nursing station.
When questioned about the incident, the nursing assistant acknowledged the failure and stated that practicing hand hygiene was important to prevent spreading infection to residents. The facility's Infection Preventionist confirmed that staff should wash hands before and after all resident care activities.
Hand hygiene represents the most fundamental infection prevention practice in healthcare settings. Proper handwashing removes pathogens that can cause healthcare-associated infections, which affect approximately 1.7 million hospitalized patients annually according to the Centers for Disease Control and Prevention. In nursing homes, where residents often have compromised immune systems and multiple chronic conditions, these infections can lead to serious complications including pneumonia, urinary tract infections, and bloodstream infections.
The facility's own policy emphasizes hand hygiene as "the primary means to prevent the spread of infection" and requires employees to wash hands after handling body fluids or excretions for at least 15 seconds using soap and water or alcohol-based hand sanitizers.
Shared Smoking Equipment Creates Cross-Contamination Risk
Inspectors also identified concerning practices in the facility's smoking area, where residents shared protective aprons without disinfection between uses. During observation of the smoking patio, surveyors noted residents removing aprons after smoking, with other residents immediately putting on the same aprons without any cleaning or disinfection process.
An Activity Assistant supervising the smoking area acknowledged that aprons were not being disinfected after each use and stated this practice placed residents at risk for infection. The Director of Nursing confirmed that smoking aprons should be disinfected after each use to prevent spreading infection between residents.
Shared equipment and clothing items can harbor various pathogens, including respiratory viruses, bacteria, and fungal organisms. When contaminated items are passed between individuals without proper disinfection, they create direct pathways for disease transmission. This risk is particularly significant for respiratory pathogens, which can survive on fabric surfaces and be transmitted through close contact.
The facility's infection prevention policy requires that "all reusable items and equipment requiring special cleaning, disinfection, or sterilization shall be cleaned" to maintain a safe environment and prevent transmission of communicable diseases.
Room Size Deficiencies Impact Care Quality
In addition to infection control issues, inspectors found that 20 of the facility's 78 resident rooms failed to meet federal space requirements. Multiple-occupancy rooms contained less than the required 80 square feet per resident, with some three-bed rooms providing as little as 214 square feet total space instead of the mandated 240 square feet.
Room sizes ranged from 214.7 to 234.6 square feet for three-bed rooms, falling short of federal standards designed to ensure adequate space for resident care, mobility, and privacy. The Administrator acknowledged the space deficiencies during the inspection.
Adequate room space is essential for proper resident care, allowing healthcare workers to safely maneuver equipment, assist with transfers, and provide treatments. Cramped conditions can impede emergency response, limit infection control measures, and compromise resident dignity and privacy.
The facility has requested a federal waiver for the undersized rooms, arguing that residents can still move freely and that the space limitations do not adversely affect health and safety. However, federal room size standards exist to ensure consistent care quality and resident rights across all nursing facilities.
Infection Prevention Standards in Long-Term Care
Federal regulations require nursing homes to maintain comprehensive infection prevention and control programs designed to provide safe, sanitary environments. These programs must address hand hygiene, equipment disinfection, isolation procedures, and staff training to prevent healthcare-associated infections.
Effective infection control becomes even more critical in congregate living settings like nursing homes, where residents live in close proximity and often share common areas and activities. Vulnerable populations, including elderly residents and those with chronic conditions, face higher risks of infection complications that can result in hospitalization or death.
The COVID-19 pandemic highlighted the importance of robust infection prevention practices in nursing homes, where early outbreaks resulted in devastating resident outcomes. Since then, federal oversight of infection control practices has intensified, with inspectors paying closer attention to hand hygiene compliance, equipment cleaning protocols, and staff adherence to prevention policies.
Regulatory Response and Corrective Actions
The violations identified at Torrance Care Center West were classified as having potential for minimal harm, indicating that while actual harm did not occur, the deficient practices created risk for residents. The facility must submit a plan of correction addressing each violation and demonstrating how it will prevent similar issues in the future.
Typical corrective measures for infection control violations include enhanced staff training, increased monitoring of hand hygiene compliance, revision of cleaning and disinfection protocols, and implementation of quality assurance measures to ensure sustained compliance.
For room size deficiencies, facilities may seek federal waivers if they can demonstrate that smaller rooms do not compromise resident health, safety, or quality of care. The waiver process requires detailed justification and ongoing monitoring to ensure resident needs are met despite the space limitations.
The inspection findings will be considered during the facility's next annual survey and may influence its overall compliance rating and participation in federal Medicare and Medicaid programs. Repeated or worsening violations could result in enforcement actions including monetary penalties, denial of payments for new admissions, or termination from federal programs.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Torrance Care Center West, Inc from 2024-07-26 including all violations, facility responses, and corrective action plans.
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