Infection Control Mistakes

Michigan investigators found that a nursing home lost 33 residents to COVID-19 because infection control mistakes spread the fatal disease. Samaritas Lodge’s 33 COVID-19 deaths are the most of any nursing home in West Michigan. At Samaritas Lodge, 78 residents have tested positive, along with 24 workers, state records show. State inspectors spent nearly a week at the home in response to the deaths. They cited the home for fatal infection control violations.

Poor Training on Infection Prevention

Inspectors found staff in the kitchen not washing their hands properly — or at all.

The investigators saw a worker using a mechanical lift on a resident without sanitizing it before or after, violating infection control standards.

They also found the plastic seal on the door leading to the home’s COVID-19 unit unzipped.  The two workers were not wearing PPE properly.  While assigned to that unit, they had their personal protection goggles on top of their heads.

“Certainly those infection control measures should have been mandated to be in place, which I’m sure they were, but weren’t being followed at the moment,” the ombudsman said. Not sure how the ombudsman was so sure.

Poor Infection Control

The facility made one big fatal mistake when the staff moved a high risk resident in with a low risk resident.  The high risk resident left four days a week for dialysis. The other woman had “no potential for community exposure”. She was confined to her room, the report stated. About two weeks later, the woman on dialysis, who had been in a private room, tested positive for COVID-19. Nine days later, the other woman tested positive.

The facility made the move even though confidential informants had warned nursing home administrators against the decision.

“My concern was that (the dialysis patient) was already at risk if she was going back (to dialysis) four times a week and exposing (the other woman) potentially,” one informants said. “But that was the way they (administrative staff) wanted it.”

Another informant said the woman on dialysis wore a mask during her appointments but the “administrative team ‘could have done more’ to protect residents in the facility,” according to the report.

“That didn’t meet best practices, nor do I think it was the guidelines that were set forth at that time,” she said.