Improper Handling of Soiled Linens and PPE Use
Penalty
Summary
The facility failed to adhere to proper hygiene and use of personal protective equipment (PPE) practices as per infection control standards when handling soiled linens. A Certified Nursing Assistant (CNA) was observed leaving a room with a bag of dirty linens in a plastic bag while wearing a glove on her right hand. She entered another resident's room, interacted with the resident, and removed the glove without performing hand hygiene. The CNA then grabbed hospital gowns from a chair with her ungloved hand and left the room without placing them in a plastic bag, subsequently leaving them in the soiled utility room. The CNA acknowledged her actions, stating she was overwhelmed with tasks and did not have time to follow proper procedures. She admitted to bringing soiled linens from one room to another and wearing gloves in the hallway, which was against the facility's infection control policy. The Director of Nursing confirmed that the CNA's actions were not in line with the facility's policy, which requires staff to remove and discard PPE before leaving a resident's room and to handle soiled linens appropriately to prevent the spread of infection.
Plan Of Correction
Preparation and/or execution of this plan does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth on the statement of deficiencies. This plan of correction is prepared and/or executed solely because required. (a) What corrective action(s) will be accomplished for those residents found to have been affected by the practice: On the Unit Manager re-educated CNA (C) on control techniques including ensuring soiled linens are not brought from resident room to resident room, gloves are not worn in the hallway and proper hygiene is to be completed prior to donning gloves and after doffing gloves. (b) How you will identify other residents having potential to be affected by the same practice and what corrective action will be taken: On the Director of Nursing/designee completed an observational audit of nursing staff to identify other residents having the potential to be affected by ensuring: 1. Soiled linens are not brought from resident to resident rooms. 2. Gloves are not worn in the hallway. 3. Proper hygiene is conducted prior to donning of gloves and after doffing of gloves. Any concerns identified were immediately addressed. (c) What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur: On the Director of Nursing/designee re-educated the nursing staff on the components of this regulation and completed an observational audit of nursing staff with emphasis on ensuring: 1. Soiled linens are not brought from resident to resident rooms. 2. Gloves are not worn in the hallway. 3. Proper hygiene is conducted prior to donning of gloves and after doffing of gloves. Newly hired nursing staff will be educated on these components during orientation. (d) How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put into place: The Director of Nursing/designee will conduct an observational audit of at least 10 nursing staff members 3 times weekly X 4 weeks and then weekly X 2 months to ensure: 1. Soiled linens are not brought from resident to resident rooms. 2. Gloves are not worn in the hallway. 3. Proper hygiene is conducted prior to donning of gloves and after doffing of gloves. Findings of these audits will be reviewed in the QA/Risk Management meeting monthly until such time as the committee determines substantial compliance has been achieved.