Failure to Maintain Infection Control During Medication Pass and Linen Delivery
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, as evidenced by multiple observed lapses in infection control practices involving both medication administration and laundry handling. During medication administration, a medication aide (MA B) was observed repeatedly failing to perform hand hygiene between residents and not sanitizing the blood pressure cuff or the medication cart after use with each resident. Specifically, MA B used the same uncleaned blood pressure cuff on several residents, placed it back on the medication cart without cleaning, and did not consistently perform hand hygiene between residents, contrary to facility policy and infection control standards. Additionally, the facility did not ensure that laundry staff handled and stored linens in a manner that maintained cleanliness and prevented cross-contamination. Laundry staff were observed transporting and delivering linens using carts that were partially or fully uncovered while moving through resident areas and during delivery. This practice left clean linens exposed to potential contamination from the environment and resident contact, which was acknowledged by staff as being against facility policy. Interviews with staff, including laundry staff, medication aides, CNAs, LVNs, and the administrator, confirmed knowledge of the facility's policies requiring hand hygiene between residents, cleaning of equipment between residents, and keeping linen carts covered at all times. Despite this, the observed practices did not align with these policies. Record reviews for the involved residents indicated that they were cognitively impaired and had various medical conditions, including chronic diseases and infections, which could increase their vulnerability to infection. The facility lacked a specific policy for sanitizing equipment between residents, further contributing to the deficiency.