Infection Control Failures in Environmental Cleaning, Linen Handling, and Precaution Implementation
Penalty
Summary
The facility failed to adhere to infection control standards in several areas, as observed and confirmed through staff interviews. In one instance, a resident with multiple diagnoses including traumatic brain injury, diabetes, aphasia, dementia, and other conditions was found to have a wheelchair with cracked and peeling vinyl armrests, exposing foam and metal. Multiple staff members, including a nursing assistant, medication aide, nurse manager, DON, infection control preventionist, and housekeeper, all acknowledged that the damaged armrests could not be properly cleaned and posed an infection control concern due to their inability to be disinfected effectively. Additionally, the facility did not ensure that personal laundry was transported in a manner that prevented contamination. A laundry aide was observed leaving a laundry cart uncovered and unattended in a hallway, with personal laundry visible and accessible. The aide later acknowledged that the cart should have been covered to prevent contamination, as per facility policy, which requires linen to be handled and transported in a way that avoids exposure and contamination. The facility also failed to implement timely transmission-based precautions (TBP) for a resident who exhibited symptoms of a possible gastrointestinal illness, including multiple episodes of nausea and vomiting. Despite these symptoms being documented in the resident's progress notes, staff did not initiate TBP or use additional personal protective equipment beyond gloves until the infection control preventionist reviewed the case the following day. The facility's policy and CDC guidelines require TBP to be implemented for residents with suspected communicable diseases, but this was not done promptly.