Infection Control Lapses in PPE Use, Catheter Care, and Laundry Practices
Penalty
Summary
The facility failed to observe infection control measures for three residents, as evidenced by direct observations and staff interviews. In one instance, a treatment nurse did not change gloves or perform hand hygiene after repositioning a resident with dementia and sepsis before continuing wound care. The nurse continued the wound care treatment using the same gloves, contrary to facility policy and infection control standards. Both the Director of Nursing and the Infection Preventionist Nurse confirmed that gloves should have been changed and hand hygiene performed to prevent the spread of infection. In another case, a licensed vocational nurse administered medications to a resident with sepsis and pneumonia and then, without doffing PPE or performing hand hygiene, exited the resident's room and touched the medication cart. The nurse acknowledged this lapse, and both the DON and IPN confirmed that PPE should have been removed and hand hygiene performed before leaving the room and handling the medication cart, as per facility policy. The facility's infection prevention and hand hygiene policies specifically require hand hygiene after glove removal and after contact with objects in the resident's vicinity. Additionally, a resident with an indwelling catheter was observed being transported by a certified occupational therapy assistant while the catheter drainage bag was touching the floor. The assistant stated the bag must have become unhooked, and both the Director of Rehabilitation and DON confirmed that the bag should be kept off the floor to prevent infection. Furthermore, a load of soiled linens was washed in a machine with water that did not reach the required temperature according to facility policy. The maintenance director and infection preventionist nurse confirmed that the water temperature was below the required 160°F, which is necessary to disinfect linens and prevent the spread of infection.