Infection Control Failures in Resident Care and Laundry Handling
Penalty
Summary
The facility failed to maintain proper infection prevention and control practices in several areas, as observed and documented by surveyors. In one instance, a certified nursing assistant (CNA) did not follow correct hand hygiene and glove-changing protocols while providing incontinent and catheter care to a 94-year-old male resident with multiple diagnoses, including heart failure, sepsis, and acute kidney failure. The CNA performed care on the resident's buttocks and then applied a clean brief without changing gloves or sanitizing hands, and subsequently touched the resident's pants with contaminated gloves. Interviews with other staff confirmed that the CNA did not follow the expected sequence of care or proper hygiene practices, which could lead to contamination and infection. Another deficiency was identified when a female resident with a urinary tract infection caused by vancomycin-resistant enterococcus (VRE) was not placed on contact isolation after laboratory results confirmed the presence of this resistant organism. The Director of Nursing (DON), who also served as the Infection Control Practitioner (ICP), was unaware of the VRE result and did not initiate appropriate isolation precautions. Staff interviews revealed that the standard practice was to place residents with VRE on contact isolation to prevent the spread of infection, but this was not done until much later, after the oversight was discovered. Additionally, the facility's laundry room was found to have multiple instances of clean and soiled laundry items, including resident clothing and lift pads, stored directly on or touching the floor. The housekeeping supervisor acknowledged that this practice was not in line with infection control standards and could result in cross-contamination. Observations showed that items were placed back into circulation after touching the floor, and staff responsible for laundry oversight did not consistently ensure proper storage and handling of laundry to prevent contamination.