Failure to Ensure Proper PPE Use in Laundry Handling
Penalty
Summary
The facility failed to ensure that laundry staff had the proper personal protective equipment (PPE) necessary to handle linens in a manner that would prevent the spread of infection. During a survey, it was observed that laundry aides were emptying dryers and handling both clean and soiled linens without the use of gowns or aprons. When questioned, one laundry aide was unaware of any PPE requirements when handling dirty linens, and no gowns or aprons were observed in the laundry area. Another staff member, who was new to laundry and housekeeping, also did not know if PPE was required and attempted to look up the information online during the survey. Further interviews revealed inconsistencies in the use of laundry bags for soiled and isolation linens. While some staff described using water-soluble bags for isolation linens, others were observed using clear plastic bags that were not biodegradable for dirty laundry. There was confusion among staff regarding which bags should be used for isolation and whether PPE was necessary when handling soiled linens. Additionally, laundry aides were seen folding clean linens in a manner that allowed the linens to touch their clothing, and no PPE aprons were available in the area. A review of the facility's policies indicated that standard precautions, including the use of gloves and gowns when handling potentially infectious materials or soiled linens, were required. The policies also specified that soiled linen should be handled with gloved hands and an apron or gown, especially for residents on transmission-based precautions. Despite these written policies, the observed practices in the laundry area did not align with the facility's infection prevention and control program requirements.
Plan Of Correction
483.80(e) Linens. Personnel must handle, store, process, and transport linens so as to prevent the spread of infection. Element #1. The Policy on Linen Management was updated on 6/4/2025. The laundry room personnel and the [R] were immediately in-serviced by the Infection Preventionist/Director of Nursing on the updated Linen Management Policy, especially regarding PPE and apron/gown use while handling soiled linens. Laundry personnel also received instructions on PPE supplies, gowns, and aprons. These items are readily available in the washing machine area for use by laundry personnel by the Infection Preventionist and the housekeeping director. Element #2 All residents have the potential to be affected by these deficient infection control practices. Element #3. All housekeeping and laundry personnel and the [R] were in-serviced on 6/19/2025 and educated by the Infection Preventionist on laundry and linen handling, and use of PPE/gowns/aprons. A PPE sign-off log will be present for the laundry staff to sign off daily that they are using proper PPE for infection control purposes. Element #4. For three (3) months (from 6/6/25 till 9/6/25), the Housekeeping Director and Infection Preventionist will monitor linen handling (3) times weekly for (4) weeks, then weekly for (2) months, then monthly thereafter for laundry personnel's compliance with infection prevention over the next two quarters. The Infection Preventionist and Nursing Director or designee will review the results of these audits, including any actions taken for correction. All findings to be reported and discussed by the next two QAPI meetings.