Failure to Adhere to Infection Control Protocols and Proper Linen Storage
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by multiple staff not adhering to required personal protective equipment (PPE) protocols and improper linen storage. In one instance, an Activities Assistant entered the room of a resident on droplet precautions without donning a mask or any PPE, despite clear signage at the door indicating the need for a surgical-grade mask. The staff member admitted to not reading the sign before entering and was unaware of the specific requirements, even after reviewing the sign post-incident. The resident in question had respiratory symptoms and was under physician-ordered droplet precautions. In two other cases, Certified Nursing Assistants and another staff member failed to wear isolation gowns and gloves while performing high-contact activities, such as transferring, oral hygiene, and other ADL care, for residents on Enhanced Barrier Precautions (EBP) due to the presence of wounds or indwelling devices like a g-tube. Despite signage and facility policy requiring gowns and gloves for these activities, staff either forgot or neglected to follow the protocol. Interviews confirmed that staff were aware of the requirements but did not comply during the observed care activities. Additionally, the facility was observed to be using linen cart covers made of loosely woven, permeable material, which staff and supervisors acknowledged would not adequately protect clean linens from environmental contaminants. The facility's own policy required clean linen to be transported in covered carts to prevent contamination, but the covers in use allowed air and liquids to pass through, potentially exposing linens to bacteria and viruses.