Failure to Follow Infection Control Standards and Inconsistent Infection Preventionist Oversight
Penalty
Summary
The facility failed to adhere to infection control standards, as evidenced by laundry staff not wearing appropriate personal protective equipment (PPE) while handling soiled laundry. Specifically, an environmental aide was observed sorting dirty laundry without a gown or gloves. When the staff member attempted to don a gown, she initially put it on incorrectly and, after correcting it, still failed to apply disposable gloves before resuming her duties. This lapse in PPE use occurred during the handling of potentially contaminated linens, contrary to facility policy and infection control protocols. Additionally, the facility did not ensure consistent implementation of the responsibilities of the Infection Preventionist (IP). The DON reported assuming IP duties after discovering that the previous IP, the ADON, was not completing required tasks and was subsequently terminated. The DON identified issues such as residents who should have been on Enhanced Barrier Precautions (EBP) lacking appropriate signage and PPE, while others had unnecessary signage. Infection surveillance mapping was incomplete for recent months, and these failures were not in alignment with the facility's own infection prevention and control program policies.