Multiple Lapses in Infection Control and Enhanced Barrier Precautions
Penalty
Summary
The facility failed to maintain infection control standards in several key areas, as observed during surveyor visits. In the laundry room, a laundry aide placed personal prescription glasses on a table designated for clean laundered gowns, a practice acknowledged by staff and management as inappropriate and contrary to facility policy. This action risked contamination of clean linens intended for resident use. During tube feeding care, a resident receiving enteral nutrition via a jejunostomy tube was observed multiple times with the end of the feeding tube left uncapped and exposed for over an hour before being reattached. This was in direct violation of the facility's policy requiring infection control precautions to minimize contamination risk during feeding tube care. The feeding formula and tubing were left uncovered on the IV pole, with photographic evidence obtained by surveyors. The facility also failed to adhere to Enhanced Barrier Precautions (EBP) and CDC guidelines for several residents requiring such measures due to the presence of devices like tracheostomies and feeding tubes. Staff were observed entering and exiting EBP rooms without performing hand hygiene, handling respiratory supplies without proper hand hygiene, and using shared equipment such as a Hoyer lift without cleaning it between uses. These lapses were confirmed through interviews and direct observation, and were inconsistent with both facility policy and CDC recommendations for infection prevention.