Failure to Follow Infection Control Practices During Incontinence Care and Linen Handling
Penalty
Summary
The facility failed to ensure proper infection control practices during incontinence care and the handling of contaminated linens for two residents on contact precautions. For one resident with a history of multidrug-resistant organism (MDRO) infection and an active urinary tract infection, a staff member changed bed linens while wearing gloves, mask, and shoe covers, but did not wear a gown as required by the facility's infection control policy. The staff member later acknowledged that gowns were not available in the PPE bin but admitted that a gown should have been worn during the procedure. The infection preventionist confirmed that contact precautions, including the use of gowns for handling bed linens, were in place for this resident. In another instance, a staff member providing incontinence care to a resident with severe cognitive impairment placed wet wipes directly on the resident's bedside rail without a barrier, contrary to facility policy. Both the infection preventionist and the staff member acknowledged that this practice did not follow the established procedures for infection prevention. The facility's perineal care policy specifies the use of barriers for supplies to prevent infection, which was not adhered to during the observed care.