Infection Control Failures in EBP, Laundry Sanitation, and Wound Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by several observed deficiencies. In one instance, staff did not follow Enhanced Barrier Precautions (EBP) for a resident with a percutaneous endoscopic gastrostomy (PEG) tube. Although the resident had physician orders and a care plan indicating the need for EBP, including gown and glove use during direct care activities such as transfers, a certified nursing assistant (CNA) was observed transferring the resident without wearing a gown, despite EBP signage and available personal protective equipment (PPE) at the room. Additionally, the facility's laundry department was found to be unsanitary, with excessive lint and dust present in and around the dryers, on the walls, and hanging from the ceilings. The administrator confirmed that the laundry area was not maintained in a clean and sanitary condition, as required for infection control. A further deficiency was observed during wound care for a resident with multiple comorbidities, including diabetes, chronic kidney disease, and an open wound on the left great toe. The treatment nurse contaminated a 4x4 gauze by placing it on a computer keyboard and then used the contaminated gauze during wound care, rather than discarding it. The nurse acknowledged the error, confirming that the wound care supplies were not kept sterile during the procedure.