Failure to Prevent Cross-Contamination During Resident Care and Soiled Linen Handling
Penalty
Summary
The facility failed to prevent cross-contamination during resident care and the handling of soiled materials, as observed in multiple instances involving both nursing and support staff. During wound and incontinence care for a resident with a pressure wound, a nurse handled a garbage can with gloved hands and then touched the resident’s wound without changing gloves or performing hand hygiene. The same nurse also failed to change gloves or clean hands after handling a soiled brief before touching clean areas and linens. These actions were acknowledged by both the nurse and the Director of Nursing as improper and contrary to the facility’s infection control procedures. During meal service, staff members were observed feeding multiple residents consecutively without cleaning their hands between residents. One CNA fed two residents in succession, and a nurse fed two others, both using the same hand and utensils without performing hand hygiene between residents. The Director of Nursing confirmed that hand hygiene should have been performed between residents to prevent cross-contamination. In the laundry area, soiled mop heads and cleaning items were stored in uncovered containers, and bags of soiled clothing were left open on the floor. Staff were seen bringing additional soiled items into the laundry room and placing them on the floor. The Director of Nursing stated that soiled items should be covered and not placed on the floor to prevent the spread of bacteria. Additionally, during incontinence care for another resident, a CNA was observed retrieving gloves from her pocket and reusing them during care, and did not consistently perform hand hygiene between glove changes. The CNA stated she did not believe hand hygiene was necessary after every glove removal, except when placing a new brief.