Infection Control Lapses in Hand Hygiene, Barrier Precautions, and Laundry Handling
Penalty
Summary
The facility failed to implement an effective infection prevention and control program, as evidenced by multiple observed lapses in infection control practices among staff. In one instance, a nurse was observed preparing and administering medications to a resident, washing the resident's feet, and applying medicated cream without performing hand hygiene between glove changes. The nurse also removed unused gloves from the clean supply, handled them with unwashed hands, and returned them to the box, further breaching infection control protocols. The nurse only performed hand hygiene after handling dirty laundry, not between other critical steps as required. The unit nurse manager confirmed that staff are expected to perform hand hygiene between glove changes, which was not followed in this case. Another deficiency was observed with a geriatric nurse aide providing morning care to a resident on Enhanced Barrier Precautions (EBP) due to a wound and dialysis access. The aide wore gloves but failed to wear a gown during high-contact care activities, despite signage and policy requiring both gloves and gowns for such residents. The aide acknowledged removing the gown after it became wet and continuing care without replacing it. Additionally, the facility's laundry practices were found deficient, with soiled linen bins lacking lids and proper labeling, and clean laundry bins being brought into the soiled area without clear separation. Staff reported that bins have never had lids and are only cleaned biweekly, and the Director of Environmental Services confirmed the ongoing issue with uncovered soiled linens.