Multiple Infection Control Failures Identified
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, resulting in multiple deficiencies across several units. Housekeeping staff were observed not performing appropriate hand hygiene between cleaning resident rooms, specifically failing to change gloves and sanitize hands after cleaning one room and before entering another. This was in direct violation of both CDC guidelines and the facility's own policies, which require hand hygiene before donning gloves and after removal, as well as between clean and dirty tasks. In the laundry room, staff did not keep clean and soiled laundry separate as required. Soiled laundry was observed crossing designated boundaries marked by black tape, with soiled items encroaching into areas meant for clean laundry. Additionally, soiled rags were stored in a cart located in the clean area, contrary to the intended separation of clean and dirty zones. The maintenance director acknowledged the improper placement and the need for a different location for soiled rags. Further deficiencies included improper handling of plastic drinking cups by staff, who were seen placing fingers inside cups while filling them with ice and placing cups face down on an unsanitized cart. Tracheostomy care for a resident was not performed in a sanitary manner, as the nurse failed to sanitize the table surface before placing clean supplies, did not change gloves or perform hand hygiene between dirty and clean tasks, and used a dressing that had fallen on an unsanitized surface. Additionally, a urinary catheter drainage bag for another resident was found stored in a bathtub with urine still inside, and the tubing was resting in a soap dish, which staff confirmed was not a sanitary practice.