LAWRENCEVILLE, GA - A recent complaint investigation at Life Care Center of Lawrenceville documented multiple infection prevention and control failures, including improper storage of respiratory equipment and inadequate hand hygiene practices during patient care.
Respiratory Equipment Storage Violations
Inspectors identified significant concerns regarding the storage of respiratory therapy supplies for a resident requiring frequent nebulizer treatments. The resident, admitted with multiple serious conditions including chronic pulmonary edema, acute and chronic respiratory failure with hypoxia, post-COVID-19 complications, heart failure, and stroke, had physician orders for nebulizer treatments four times daily to manage shortness of breath.
During observations on January 28 and 29, 2025, surveyors found the resident's nebulizer mask and tubing lying unbagged on the nightstand, tangled and touching the floor. The equipment remained improperly stored despite not being in active use. When questioned, the attending nurse opened the nightstand drawer to reveal a properly labeled storage bag that should have been used for the respiratory supplies.
Medical Significance of Proper Equipment Storage
Respiratory therapy equipment requires careful handling and storage protocols because it comes into direct contact with a patient's airway. When nebulizer masks and tubing are left exposed to environmental contaminants—particularly when touching non-sterile surfaces like floors—they can become colonized with bacteria, viruses, and fungi. For patients with compromised respiratory systems, exposure to these pathogens through contaminated equipment can lead to serious respiratory infections, pneumonia, or exacerbation of existing chronic lung conditions.
The facility's own policy, revised in October 2024, clearly specified that oxygen and respiratory supplies should be stored in bags labeled with the resident's name when not in use. This protocol serves multiple purposes: it prevents environmental contamination, reduces cross-contamination risks, and maintains the cleanliness of equipment between treatments. For a resident receiving treatments four times daily with existing respiratory failure and post-COVID complications, proper equipment storage becomes even more critical to prevent additional respiratory complications.
Hand Hygiene and Equipment Sanitation Failures
Inspectors documented concerning hand hygiene practices during a medication pass observation on January 29, 2025. A registered nurse was observed performing a blood glucose check on a resident without washing or sanitizing hands before gathering supplies or entering the room. Additionally, the nurse failed to clean and disinfect the glucose meter before use—a critical step when using shared medical equipment between patients.
When questioned, the nurse acknowledged that sanitizer had been removed from the medication cart and she had forgotten to perform hand hygiene. The nurse confirmed understanding that hand sanitization should have occurred before supply preparation and room entry, and that the glucometer required cleaning before use.
Understanding Hand Hygiene in Healthcare Settings
Hand hygiene represents one of the most fundamental and effective infection prevention measures in healthcare environments. Healthcare workers' hands serve as the primary vector for transmitting pathogens between patients, particularly in settings where staff care for multiple residents with varying health conditions and immune system capabilities.
The facility's hand hygiene policy, revised in June 2024, clearly outlined expectations for staff to perform hand hygiene before and after contact with residents, after contact with objects in the resident's environment, and after removing personal protective equipment. The policy specified that staff should use either alcohol-based hand sanitizer or, after three consecutive sanitizer applications, wash hands with soap and water.
Blood glucose monitoring presents particular infection risks because it involves breaking the skin barrier and potential exposure to blood. Shared glucose meters moving between residents can transmit bloodborne pathogens if not properly cleaned between uses. Standard protocols require cleaning and disinfecting glucose meters before and after each resident use to prevent cross-contamination.
Industry Standards and Expected Practices
Healthcare facilities are required to maintain comprehensive infection prevention and control programs under federal regulations. These programs must include policies addressing equipment storage, hand hygiene, and medical device sanitation. The facility's corporate nursing leadership confirmed during interviews that staff were expected to store respiratory supplies in labeled bags when not in use, perform hand hygiene before and after resident contact, and clean shared medical equipment between patients.
Additional Issues Identified
The investigation documented that these infection control lapses occurred during routine care observations, suggesting potential systemic issues with policy implementation and staff compliance monitoring. The violations affected residents receiving respiratory therapy and those requiring blood glucose monitoring, though the full scope of affected residents was not specified in the inspection report.
The Staff Development Coordinator and Interim Infection Control Preventionist confirmed awareness of proper protocols and stated that staff education emphasized these requirements. However, the documented violations indicated gaps between policy expectations and actual practice at the point of care.
The January 30, 2025 inspection classified these findings as having potential for actual harm, though no specific adverse outcomes were documented in the available inspection narrative. The facility was cited for failing to properly implement its infection prevention and control program, with inspectors noting that the deficient practices increased risks for infection spread, equipment contamination, and other health complications.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Life Care Ctr of Lawrenceville from 2025-01-30 including all violations, facility responses, and corrective action plans.
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