Infection Control Failures in Hand Hygiene, Linen Handling, Equipment Cleaning, and Water Management
Penalty
Summary
The facility failed to ensure proper infection prevention and control practices in several key areas. Staff did not perform adequate hand hygiene when entering and exiting a resident's room under Enhanced Barrier Precautions (EBP), nor did they demonstrate understanding of the EBP signage or requirements. Both an Activities Aide and a Certified Nursing Assistant entered the room without performing hand hygiene, handled items within the room, and wore artificial nails that extended beyond the fingertips, contrary to infection control recommendations. The resident involved was cognitively intact and had a stage 2 pressure wound, increasing the importance of proper infection control. Additionally, clean linens were observed being transported improperly, with a CNA carrying towels and washcloths under her arm, allowing them to come into contact with her clothing and exposed skin. This practice was acknowledged by the Infection Preventionist as inappropriate due to infection control concerns. Shared resident equipment, such as mechanical lifts, was found to be visibly soiled with dirt, dust, and dried substances, and staff interviews confirmed that such equipment should be cleaned after each use to prevent cross-contamination. The facility also failed to maintain an effective water management program to prevent Legionella. The Maintenance Director was unaware of the facility's protocols for Legionella prevention, including water sampling and documentation of flushing procedures for off-line rooms. There were no logs or evidence of compliance with the facility's policy, which requires regular cleaning, disinfection, and documentation to minimize the risk of Legionella and other water-borne pathogens.