Failure to Maintain Infection Control Practices for Resident Items and Linen Storage
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by multiple observed deficiencies in resident care and environmental management. In one instance, a resident with chronic obstructive pulmonary disease, protein-calorie malnutrition, and dementia was found lying in a low bed with a glass of water and a desk phone placed on the floor beside the bed. Additionally, the resident's urinal bottle was not labeled with the resident's name or room number. Staff interviews confirmed that placing personal items on the floor could lead to contamination and that urinals should be labeled to prevent cross-contamination between residents. Further observations revealed that staff repeatedly left mobile linen carts open in the hallway after obtaining supplies, with the carts facing resident rooms. Staff members acknowledged that leaving the carts open exposed clean linens to environmental contaminants, and that clean linens were touched with gloves and PPE after providing resident care, increasing the risk of contamination. Facility policy required that linen carts be covered at all times to prevent contamination, but this was not consistently followed. Additionally, some mobile linen carts were covered with mesh or permeable materials, which staff recognized as inadequate for protecting linens from environmental contaminants. Although there was an effort to replace these covers with non-permeable materials, not all carts had been updated. Facility policies reviewed indicated the importance of proper labeling, storage, and handling of resident care items and linens to prevent infection, but these procedures were not consistently implemented.