Infection Control Deficiencies: Inadequate Hand Hygiene and Improper Cleaning of Soiled Furniture
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by inadequate hand hygiene during wound care and improper cleaning of soiled furniture. One resident with severe cognitive impairment, a history of urinary tract infections, and total incontinence was observed sitting in a fabric recliner that was saturated with urine. Certified Nurse Aides transferred the resident to be cleaned and changed but did not immediately clean or disinfect the soiled chair. Housekeeping later cleaned the chair using only hot water in a shampooer, without any disinfectant chemicals, and the chair remained visibly stained and wet for several hours. Staff interviews revealed inconsistent understanding and application of cleaning protocols, with some staff believing hot water alone was sufficient and others stating that soiled cloth chairs should be discarded or disinfected with germicidal wipes. Additionally, a licensed nurse was observed performing wound care on another resident without following proper hand hygiene protocols. The nurse donned gloves and a gown without performing hand hygiene, removed and cleaned wounds, and changed gloves multiple times without washing hands between glove changes or before applying clean dressings. The nurse also removed personal protective equipment in the incorrect order and failed to perform hand hygiene at required points during the procedure. The nurse later acknowledged these lapses and described the correct procedures, which were not followed during the observed care. Facility policies required maintaining a safe, sanitary, and comfortable environment to prevent and manage the transmission of infections. However, observations and staff interviews demonstrated that these policies were not consistently implemented, resulting in practices that could contribute to the spread of infection among residents.