Failure to Discard Single-Dose Acetic Acid and Unauthorized Access to Clean Laundry Area
Penalty
Summary
The facility failed to implement proper infection prevention and control measures in two distinct situations. In the first instance, a single-dose container of acetic acid, used to prevent blockage in tubes connected to residents, was not discarded after being opened. The container was labeled with the date it was opened and was found stored in a treatment cart several days later. Interviews with the LVN, DON, and Infection Preventionist confirmed that the acetic acid was a single-dose, preservative-free solution, and manufacturer instructions required prompt use and immediate disposal of any unused portion. Facility policy also required medications to be stored and handled according to manufacturer recommendations, which was not followed in this case. In the second situation, a non-laundry staff member entered the restricted clean area of the laundry department and removed clean linens from a linen cart. Observations and interviews with the Environmental Services Supervisor, Infection Preventionist, and DON confirmed that only laundry staff were permitted to handle clean linens in the clean area, and non-laundry staff were required to remain outside this area. Facility policies on infection prevention and laundry services emphasized the importance of restricting access and handling of clean linens to prevent the spread of infection. Both deficiencies were identified through direct observation, staff interviews, and review of facility policies and manufacturer instructions. The actions taken by staff in both cases were inconsistent with established infection control protocols and facility procedures, leading to the cited deficiencies.