Infection Control Deficiencies: Soiled Linen Storage, Hand Hygiene, and Isolation Signage
Penalty
Summary
The facility failed to implement infection control practices as required by federal regulations, resulting in multiple deficiencies. During an observation of the laundry area, two uncovered bins containing soiled mops and towels were found stored in the clean laundry area. The facility's policy requires that soiled linen be collected at the point of use, placed in a designated receptacle, and kept separate from clean linen. The Housekeeping Supervisor confirmed that the soiled laundry bins should not have been in the clean area. In another instance, a wound care observation for a resident with a coccyx pressure injury revealed that the LVN performing the procedure did not follow proper hand hygiene protocols. The LVN changed gloves multiple times during the wound care process without performing hand hygiene between glove changes, contrary to the facility's policy, which mandates hand hygiene before donning and after removing gloves. The LVN acknowledged the lapse in hand hygiene during an interview. Additionally, the facility failed to ensure appropriate transmission-based precaution signage was posted for a resident with a physician's order for contact isolation due to a multidrug-resistant organism (MDRO) in the urine. Instead of the required contact isolation signage, an EBP (Enhanced Barrier Precautions) sign was posted on the resident's door. The error was confirmed by the LVN and the DON during the survey. These failures were identified through observation, interview, and review of facility policies and had the potential for cross-contamination and spread of infectious organisms.
Plan Of Correction
2. 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. All residents were potentially affected by this deficient practice. On 7/18/2025, IP nurse checked the laundry area to make sure soiled and clean areas were separated and no soiled laundry was crossing the clean laundry area. On 7/25/2025, 8/4/2025-8/8/2025, DON, DSD, and IP nurse in-serviced all staff regarding facility P&P for infection control and prevention. The in-service focused on hand hygiene, cross contamination, making sure clean and soiled laundry were separated, and isolation precautions. On 8/5/2025-8/8/2025, DON in-serviced all Licensed Nurses about facility P&P for residents with new orders of isolation and to put appropriate isolation signs immediately. 3. Measures that will be put into place or systematic change the facility will make to ensure that the deficient practice does not recur: DON and IP Nurse or designee will oversee this process. IP nurse will do random checks of the laundry area to make sure soiled laundry is not stored in the clean area. Any non-compliance will be addressed by training staff and reported to DON. IP will provide ongoing training and education to all staff about hand hygiene monthly for 3 months, and random hand hygiene compliance will be completed. Results will be reported monthly during infection control committee meetings. IP nurse will review all isolation signage to ensure residents in isolation have proper signage. Any new isolation order received by the Charge nurse will be reported to the IP nurse and discussed during the clinical meeting to ensure the plan of care was updated. Any non-compliance will be reported to DON for 3 months. 4. Facility plans to monitor the effectiveness of the corrective actions and sustain compliance; integrate QA process: DON and IP nurse will monitor the effectiveness of the process and report to the Administrator. Any findings will be presented to the Monthly QA&A and infection control meetings. The Plan of Correction was presented at the Quality Assurance (QA&A) committee meeting on 08/14/2025. Ongoing findings from audits will be reported to the QAPI/QAA monthly meetings for at least three months. Corrective action completion date: 8/23/2025