Infection Control Lapses in Hand Hygiene, PPE Use, and Laundry Handling
Penalty
Summary
The facility failed to maintain infection prevention and control practices as evidenced by multiple observed lapses in hand hygiene, use of personal protective equipment (PPE), and proper handling of clean laundry. During a medication administration observation, an LVN did not perform hand hygiene at required moments, including after removing gloves, after disinfecting equipment, and when moving between residents and their belongings. The LVN acknowledged not following the facility's hand hygiene policy, which requires hand hygiene before and after donning PPE, and when entering or exiting a resident's room. In a separate incident, another LVN performed wound care on a resident with a Stage 3 pressure injury but did not perform hand hygiene between donning and doffing gloves. The LVN was unsure about the requirement for hand hygiene during this process, despite the facility's policy and statements from other staff confirming that hand hygiene should occur to prevent cross-contamination. The resident involved had severe cognitive impairment and required specific wound care interventions as ordered by the physician. Additional deficiencies included a laundry rolling rack with clean residents' clothing that was only partially covered, with clothing touching handrails and walls, contrary to facility policy requiring clean laundry to be fully covered. Furthermore, an LVN was observed performing a dressing change on a resident's dialysis access site without wearing the required PPE, despite the resident being on Enhanced Barrier Precautions due to a dialysis catheter. The LVN confirmed knowledge of the need for PPE but did not comply during the observed procedure. Facility leadership acknowledged these findings during interviews.