Infection Control Failures in Food Handling, Linen Management, and Medication Administration
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by multiple observed breaches in infection control practices involving both staff and residents. Staff were observed handling residents' ready-to-eat food with bare hands, including a certified nurse assistant (CNA) who assisted a visually impaired resident and another resident with their meals without using gloves or utensils. In one instance, the CNA had a cut on her finger covered with a dressing while handling food, and the resident expressed discomfort with this practice. Facility policy and FDA Food Code require the use of utensils or gloves when handling ready-to-eat foods, and that any bandaged hand must be covered with a single-use glove. In the laundry area, a laundry aide was seen allowing clean linen to touch both her clothing and the floor while folding, contrary to facility policy and supervisor expectations. The supervisor and director of nursing (DON) confirmed that clean linen should not come into contact with potentially contaminated surfaces, and that linen touching the floor should be rewashed. Additionally, during medication administration, a licensed nurse was observed using a shared glucometer between residents, cleaning it with a single disinfecting wipe for multiple surfaces, and not sanitizing the insulin pen's rubber seal before attaching a needle. The nurse was unaware of the need to disinfect the pen seal and had not received specific training on proper sanitizing procedures for blood glucose monitors. Further deficiencies included nursing staff failing to perform hand hygiene or change gloves between different routes of medication administration, such as oral, inhaled, and eye medications, and after handling contaminated devices. A nebulizer face mask for a resident with chronic respiratory conditions was not changed every seven days as required by facility policy, with the equipment in use for over three weeks. These failures were confirmed by staff interviews and policy reviews, and resulted in increased risk for cross-contamination and potential exposure to infectious agents among residents, staff, and visitors.