Infection Control Lapses in Equipment Cleaning, Hand Hygiene, and Environmental Cleanliness
Penalty
Summary
Multiple deficiencies in infection prevention and control practices were identified during the survey. Staff failed to ensure that shared resident-care equipment, specifically cloth gait belts used in therapy, were disinfected according to manufacturer instructions. The cloth gait belts, made of porous material, were wiped with Super Sani-Cloth disinfectant wipes, which are only effective on non-porous, hard surfaces. Both the Infection Preventionist Nurse and the Director of Nursing confirmed that the wipes were not appropriate for disinfecting cloth gait belts, and that laundering after each use was necessary to prevent cross contamination. Hand hygiene practices were not consistently followed by staff when entering and exiting resident rooms or after providing care. Observations showed that CNAs did not perform hand hygiene before assisting residents with meals or after touching high-contact surfaces in resident rooms, including those on Enhanced Barrier Precautions due to the presence of medical devices and risk of MDRO infection. Staff interviews confirmed awareness of the hand hygiene policy, but lapses in practice were observed, including failure to use hand sanitizer or wash hands as required by facility policy and CDC recommendations. Environmental cleanliness was also found lacking, as evidenced by stained and soiled curtains in a resident's room. The resident expressed discomfort with the unclean curtains, and both nursing and housekeeping staff acknowledged that curtains should be clean and free of stains for both infection control and resident dignity. Facility policy requires a clean, sanitary, and homelike environment, but observations and staff interviews confirmed that this standard was not met in this instance.