Failure to Maintain Infection Control Practices and Enhanced Barrier Precautions
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by multiple lapses in the storage and handling of resident care items and the implementation of Enhanced Barrier Precautions (EBP). On Hall Z, clean water basins were observed stored unbagged on a shelf in the dirty linen closet, next to overflowing soiled linen, which was confirmed by laundry staff as inappropriate and a risk for cross-contamination. Additionally, opened and used resident care items, such as wipes and denture cups containing baby powder, were found on the clean linen cart instead of being left in residents' rooms as required. Staff interviews confirmed that some employees habitually returned used items to the clean linen cart, and a used bottle of skin and hair cleanser was also found on the cart. The facility also failed to implement EBP for a resident with an indwelling dialysis catheter, despite active physician orders and care plan interventions specifying the need for EBP. Observations revealed no EBP signage or PPE caddy outside the resident's room, and both the resident and staff confirmed that only gloves were used during care, with no gowns applied. Interviews with CNAs and an LPN demonstrated a lack of awareness regarding the resident's EBP status, and facility leadership acknowledged that EBP was not in place as required.