Failure to Implement Infection Control Practices
Penalty
Summary
The facility failed to implement proper infection control practices in several instances involving multiple residents. During a medication pass, a Licensed Vocational Nurse used a medication tray for one resident without disinfecting it before using it for another resident. The nurse acknowledged that the tray was not sanitized between uses, which is contrary to facility policy and infection control standards. The resident involved had diagnoses including paranoid schizophrenia and bipolar disorder and required assistance with daily activities. In another incident, a Certified Nursing Assistant handled a soiled gown from a resident with dementia, schizophrenia, and COPD by holding it close to his body and transporting it through the facility without placing it in a plastic bag or laundry barrel as required. The CNA admitted there was no plastic bag or laundry barrel available at the time and recognized that dirty linens should be kept away from staff clothing to prevent the spread of infection. The Infection Preventionist Nurse and Director of Nursing both confirmed that this practice could lead to cross contamination and was not in line with facility policy. Additionally, a resident was observed taking clean linen from a linen cart in the hallway without staff assistance. Staff interviews confirmed that residents should not access clean linen carts on their own, as this could result in cross contamination. Facility policy specifies that access to clean storage areas should be limited to staff only. These observed failures in infection control practices were confirmed through interviews and record reviews.