Failure to Follow Infection Control Procedures During Room Cleaning for Resident on Contact Precautions
Penalty
Summary
A deficiency occurred when a housekeeper/laundry aide failed to follow proper infection control procedures while cleaning the room of a resident who was on contact precautions for Clostridium Difficile (C-DIFF), a highly infectious disease. The aide entered the resident's room wearing gloves and a gown, brought in cleaning supplies, and placed them on the resident's dresser. After cleaning, the aide removed her gloves and gown, then placed the uncleaned cleaning supplies on top of an open box of clean gloves on her cleaning cart outside the room, without sanitizing the items first. She also left the room without washing or sanitizing her hands, only washing them later in the soiled utility room after touching the door handle. Interviews revealed that the housekeeper was unsure about the correct procedures for handling supplies and hand hygiene when cleaning rooms under contact precautions. She acknowledged that she should have sanitized the supplies before removing them and did not realize she had contaminated the clean gloves. The environmental services supervisor and another housekeeper also demonstrated uncertainty about the correct process, with the supervisor unable to recall the last time staff competencies or audits were completed regarding infection control. The director of nursing confirmed that competencies had not been recently completed for housekeeping staff and agreed that the observed process was incorrect. Policy review showed that the facility's procedures required cleaning equipment to be sanitized after use in rooms with infectious diseases and specified that hand hygiene with soap and water was necessary after glove removal, especially for C-DIFF. However, these procedures were not followed during the observed cleaning, and staff were unclear about the correct infection control practices, leading to the potential for contamination and spread of infection.