Infection Control Deficiencies in Documentation, Linen Handling, and Hand Hygiene
Penalty
Summary
The facility failed to implement effective infection prevention and control practices as evidenced by multiple deficiencies in documentation, environmental services, linen handling, and hand hygiene. Review of the facility's monthly Infection Prevention and Control Surveillance Logs revealed discrepancies between the surveillance logs and the monthly summary reports for several months, resulting in inaccurate reporting of healthcare-associated infections (HAIs) and community-acquired infections (CAIs). The Infection Preventionist (IP) confirmed that the numbers reported did not match and acknowledged the inaccuracy of the infection data, which is used for tracking and trending infections within the facility. In the laundry area, personal items such as a tumbler cup, bottled water, and lotion were found stored on a clean linen cart, contrary to facility policy requiring clean linens to be protected from environmental contamination. Staff members were observed mishandling clean linens by holding them against their bodies while delivering them to residents' rooms, which was acknowledged by the staff as improper practice. These actions were verified by the Maintenance Supervisor, Director of Nursing (DON), and IP as not compliant with infection control policies. Additionally, a hospice aide was observed providing care to a resident with significant cognitive impairment without performing appropriate hand hygiene. After handling soiled linens with gloved hands, the aide failed to change gloves and perform hand hygiene before touching the resident. The DON confirmed that both facility and hospice staff are required to perform hand hygiene before and after resident care, and acknowledged the failure to follow this protocol.