Failure to Implement Infection Control Practices During Resident Care and Laundry Services
Penalty
Summary
Staff failed to follow professional standards of infection control during direct care and laundry services. In one instance, a resident in a persistent vegetative state with a tracheostomy, Foley catheter, and feeding tube was observed being cared for by a CNA and CMA who did not change gloves or perform hand hygiene after handling soiled items. The CMA used soiled gloves to touch clean items, such as a neck pillow and a clean brief, and did not use a fresh wipe for each cleaning pass. Additionally, a pillow that had fallen to the floor was placed back on the resident's bed and near the tracheostomy site. Staff also failed to keep the catheter bag below the level of the bladder during transfers, and some staff were unaware of this requirement. Interviews confirmed that staff were not fully aware of proper infection control practices, despite facility policies outlining these standards. In the laundry area, there was an open grate drain with standing water in front of the washing machines, and clean laundry was folded and stored in a room that also served as the dietary manager's office and housed the time clock. Non-laundry items were present on the clean folding table, and the facility's infection control policy did not address the storage and management of resident linen during the laundry process. These practices failed to ensure a sanitary environment and increased the risk of contamination.