Infection Control, Laundry Handling, and Water Management Deficiencies
Penalty
Summary
The facility failed to ensure proper infection prevention and control practices in several key areas. For one resident with chronic kidney disease, vancomycin resistance, and congestive heart failure, an LPN collected a nasal swab specimen while the resident was under droplet precautions. The LPN placed the specimen tube on the medication cart, did not sanitize the cart surface before placing other residents' medication bottles on the same area, and was unclear about hand hygiene practices between tasks. The specimen remained on the cart for an extended period, and the infection prevention RN later confirmed that the medication cart was not an appropriate location for collected specimens and that surfaces should have been sanitized to prevent contamination. In the laundry area, staff did not follow proper procedures for handling soiled linens. Laundry personnel transported uncovered bins of dirty linen through the facility, wore the same gloves while collecting soiled items from multiple locations, and entered the clean laundry area with contaminated gloves. The staff did not consistently use required personal protective equipment such as gowns or face shields, and dirty laundry was brought through the clean side of the laundry area, contrary to facility policy. The policy required separation of clean and soiled linens, use of PPE, and specific handling procedures to reduce environmental contamination, but these were not followed during the observed process. The facility also lacked an active water management program as required by its own policy. Observations revealed that water features, such as a fishpond and a fountain, were present, but there was no consistent water testing or documentation of water system flow, mixing valves, or shut-off points. Maintenance staff were unable to provide complete records of water feature maintenance or testing, and the facility's water management map was incomplete, lacking necessary details about the water system. The policy required mapping and monitoring to prevent hazards such as Legionella, but these measures were not fully implemented.