Failure to Maintain Effective Infection Control Practices
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program as evidenced by multiple lapses in infection control practices. During a lunch meal observation, a housekeeper was seen cleaning the residents’ hallway while meal trays were being distributed. The cleaning cart, which contained dirty items and garbage, was parked in the hallway near the tray cart, and the housekeeper disposed of gloves and proceeded to handle other items without performing hand hygiene. The housekeeper acknowledged awareness of the need to remove the cleaning cart before meal service and to perform hand hygiene after glove removal, but did not follow these procedures. The Infection Preventionist confirmed that staff were trained on hand hygiene and that cleaning carts should not be present during meal service due to infection control concerns. Additionally, improper cleaning of shared medical equipment was observed. After a resident with hemiplegia and contractures was transferred using a Hoyer lift, the lift was placed in a common area without being cleaned or disinfected between uses. Facility policy required cleaning and disinfecting reusable equipment between residents, especially for those with wounds or indwelling devices, but staff reported that the Hoyer lifts were only cleaned at the end of the day and not between residents. The Infection Preventionist stated that the expectation was to follow the infection control policy regarding multi-use device cleaning.