Infection Control Failures: Missing EBP Signage, PPE, and Improper Linen Storage
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program for two of four residents observed. For one resident with end stage renal disease, hypertension, atrial fibrillation, and coronary artery disease, who was admitted with a wound on his left heel and required assistance with activities of daily living, there was no Enhanced Barrier Precaution (EBP) sign posted on the door and no personal protective equipment (PPE) set up at the resident's door, despite the resident being on EBP. Multiple staff interviews confirmed that the sign and PPE should have been present to prevent the spread of infection, and staff were unclear about who was responsible for posting the sign and setting up PPE. Some staff also reported not having received in-service training on infection control procedures. Additionally, a clean, uncovered linen cart with linens was observed stored in another resident's room. Staff interviews revealed that the linen cart should not have been stored in a resident's room due to the risk of cross-contamination. While some staff had received in-service training on infection control and linen storage, others had not. The facility's policy requires clean linens to be stored in a designated space with a closed door to reduce accidental contamination. The facility's policies on clean laundry storage and enhanced barrier precautions were not followed, as evidenced by the lack of signage, PPE availability, and improper linen storage. Staff interviews indicated inconsistent knowledge and training regarding infection control practices, and monitoring systems for ensuring compliance were not effectively implemented.