Infection Control Deficiencies in Hand Hygiene, PPE Use, and Linen Handling
Penalty
Summary
Facility staff failed to implement infection control practices as required by federal regulations. During a medication pass for a resident with a G-tube feeding, an LVN did not perform hand hygiene between glove changes. Specifically, after removing gloves, the LVN touched the bed and other surfaces, then donned new gloves without hand hygiene before continuing with tasks such as turning off the G-tube machine and checking tube placement. The LVN also failed to perform hand hygiene after removing gloves to retrieve spoons from the medication cart, instead immediately donning new gloves. The resident involved had no capacity to make decisions and was on enhanced barrier precautions due to the G-tube. In another instance, a CNA did not follow enhanced barrier precautions when assisting a resident with a urostomy back to bed. Although the resident's doorway had signage indicating enhanced barrier precautions and the CNA performed hand hygiene and donned gloves, the CNA did not wear a gown as required for high-contact care activities such as transferring the resident. Both the CNA and the infection preventionist confirmed that a gown should have been worn during this type of care, as outlined in the resident's care plan and physician's orders. Additionally, the facility failed to maintain proper infection control in the laundry area. The laundry aide stored personal items, including a cell phone charger, water bottle, and flask, on the counter designated for clean laundry sorting, adjacent to clean resident linens. The laundry aide and infection preventionist both acknowledged that personal items should not be stored near clean linens to prevent contamination. These observed failures in hand hygiene, use of personal protective equipment, and linen handling posed a risk for the transmission of infectious agents within the facility.
Plan Of Correction
F880 Infection Prevention and Control • How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice. 1:1 training was done by the IP nurse with the charge nurse who failed to ensure hand hygiene was performed in between changing of gloves during med pass observation with a resident who had enteral feeding. The 1:1 training included hand hygiene and universal precautions. CN A did not follow EBP precaution when assisting the resident back to bed. CNA 4 was given a 1:1 training by the DSD on 6/16/25 on policy and procedure for Enhanced Barrier Precautions. Laundry personnel failed to ensure the laundry aide did not store personal items adjacent to the resident clean linens in the laundry sorting area. 1:1 training with the laundry aide provided by IP nurse on 7/3/25 on storage of personal items in clean working stations. The personal item was discarded and the area was sanitized per facility protocol. Maintenance director verified that the water bottle did not touch or contaminate any clothing items and that no re-washing was necessary. In-services will be provided by the IP nurse on hand hygiene, EBP practice, personal items in clean working stations by 7/10/25. • How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken. On 6/18/25, the DSD did a spot check on the CNAs observing EBP practices and no other issue was noted. On 6/18, IP performed a hand hygiene audit with the nursing staff and no other issue was identified. On 6/20/25, a spot check of the laundry room was done by the IP to check for personal items near the sorting area and no other issue was found. • What measures will be put into place or what systemic changes the facility will make to ensure that the deficient practice does not recur. I.P. will do random checks on hand hygiene, EBP practices, and storing/using personal items in clean working areas 3x/week x 3 months. Report any findings to the DON. • How the facility plans to monitor its performance to make sure that solutions are sustained. IP nurse will provide a summary trend analysis of the findings to the facility's monthly QAPI Committee for 3 months or until such time as consistent substantial compliance has been achieved as determined by the committee. • Include dates when corrective action will be completed. Date of compliance: 7/10/25