Multiple Infection Control Breaches Observed
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by multiple observed breaches in infection control practices. Certified Nursing Assistant (CNA) 1 was seen drinking from a personal cup in the hallway and storing it inside a clean linen cart, despite acknowledging that this practice was not permitted due to contamination risks. CNA 1 continued to store the cup in the dirty linen cart after being observed. Additionally, CNA 2 was observed returning clean linen from a resident's bed to a clean linen cart, believing it was acceptable because the linen was in a plastic bag, but later confirmed with the Infection Preventionist that this practice was not allowed due to cross-contamination concerns. Enhanced Barrier Precautions (EBP) were not implemented as required for a resident with wound care needs. CNA 7 was observed not wearing a gown while providing care and changing bed sheets for a resident on EBP, despite being aware that a gown should be worn to prevent the spread of bacteria. Furthermore, staff failed to wear appropriate Personal Protective Equipment (PPE) when entering a contact isolation room, and gloves were worn in the hallway, contrary to facility policy and infection control standards. Additional deficiencies included the failure to date a nasal cannula and humidifier for a resident, with the nasal cannula found on the floor and both items undated. The Registered Nurse (RN) acknowledged that these items must be dated to track when they were last changed to prevent infection. Facility policies reviewed confirmed the requirements for proper linen handling, PPE use, and equipment dating, all of which were not followed as observed during the survey.