Infection Control Program Deficiencies: Housekeeping, Linen Handling, and PPE Use
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by multiple observed lapses in housekeeping, linen handling, and the use of personal protective equipment (PPE) for residents requiring enhanced barrier precautions (EBP). Housekeeping staff did not consistently perform hand hygiene before donning gloves, between glove changes, or after removing gloves. Cleaning procedures were not followed as required, with staff cleaning from dirty to clean areas, using the same cleaning materials for different surfaces, and failing to clean high-touch areas such as call lights, bed controls, and door handles. These actions were observed during the cleaning of multiple resident rooms, and staff interviews revealed a lack of awareness regarding proper hand hygiene and cleaning protocols. Linen and resident clothing were not transported in a hygienic manner. Staff were observed moving both clean and soiled linens and personal clothing items on uncovered carts through resident areas, contrary to facility policy and CDC guidelines. Soiled linens were sometimes handled without being bagged or covered, and clean linens were delivered to resident rooms without protective coverings, increasing the risk of environmental contamination. Staff interviews confirmed that linens should be covered during transport, but this was not consistently practiced. The facility also failed to ensure that staff donned appropriate PPE when providing direct care to residents who should be on EBP. For a resident with a stage 2 pressure ulcer, staff did not wear gowns and gloves during high-contact care activities such as transfers and toileting assistance, and PPE was not made available at the resident’s room. Interviews with staff indicated inconsistent understanding and implementation of EBP requirements, with some staff relying on signage or verbal instructions rather than established protocols. These failures were directly observed during care activities involving the resident requiring EBP.