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F0880
E

Failure to Follow Infection Control Protocols for Glove Use and Linen Handling

Sylmar, California Survey Completed on 04-28-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

Staff failed to adhere to infection prevention and control protocols by wearing gloves in the hallway after providing care to residents. Certified Nursing Assistants (CNAs) were observed exiting resident rooms while still wearing gloves and handling items such as dirty linens and transporting residents in a shower chair. These actions were directly observed by surveyors and confirmed through interviews with the involved staff, who acknowledged that gloves should not be worn in the hallway to prevent the spread of infection. One resident with hemiplegia and hemiparesis required substantial assistance with activities of daily living (ADLs), and a CNA was seen leaving the resident's room wearing gloves while carrying a plastic bag of dirty linens to the dirty linen room. Another resident with acute respiratory failure and hypoxia, who required moderate assistance with ADLs, was transported in a shower chair by a CNA wearing gloves in the hallway. A third resident, dependent on staff for ADLs and diagnosed with type 2 diabetes mellitus, had their soiled linens carried by a CNA without a plastic bag, with the CNA wearing gloves in the hallway and entering the dirty linen room. Interviews with the Infection Preventionist Nurse and the Director of Nursing confirmed that staff are expected to remove gloves before exiting resident rooms and perform hand hygiene to prevent infection transmission. Review of facility policies also indicated that gloves are to be discarded in the room where care is provided and that soiled linens should be placed in a plastic bag before transport. These observations and staff admissions demonstrated a failure to follow established infection control procedures, creating the potential for the spread of communicable diseases within the facility.

Plan Of Correction

F 880 F 880 F 880 Maclay Healthcare Center makes every effort to comply with the State and Federal regulations. Nothing in this plan of correction is an admission otherwise. Maclay Healthcare Center submitted this plan of correction to comply with the State and Federal regulations and does not waive any objection obtained. This plan of correction is our credible allegation of compliance for deficiency noted findings of the California Department of Public Health during the entity reported incident no. CAo0958842 which was conducted on 4/28/25. F880 Infection Prevention and Control =E Immediate Corrective Action: • On 4/28/25, Infection Prevention Nurse provided a one-on-one in-service and review with CNA 2, on the infection control and prevention policy, focusing on the importance of not wearing gloves in the hallway to prevent the spread of infection. • On 4/28/2025, Infection Prevention Nurse provided a one-on-one in-service and review with CNA 3 on the infection control and prevention policy, focusing on the importance of not wearing gloves while transporting residents in a shower chair to prevent the spread of infection. • On 4/28/2025, Infection Prevention Nurse provided a one-on-one in-service and review with CNA 4 on the infection control and prevention policy, focusing on the importance of placing soiled linens in a plastic bag prior to transporting them to the soiled linen barrel and not wearing gloves in the hallway to prevent the spread of infection. • On 4/28/25, 4/29/25, DON and IP Nurse provided an in-service to licensed nurses and CNAs regarding the use of PPE-gloves, hand hygiene/handwashing and facility policy on transporting soiled linen to the dirty linen room or soiled linen barrel to prevent the spread of infection. Other residents affected by this deficient practice: • On 4/28/2025 and 4/29/2025, the Infection Prevention Nurse and the assistant DSD staff conducted rounds during resident care and observed staff during and after care of residents to ensure that staff were removing gloves prior to exiting the resident room were performing hand hygiene/handwashing and that CNA staff are placing soiled linen in a plastic bag when transporting soiled linens in

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