Infection Control Lapses in Linen Handling and Wound Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program as evidenced by multiple lapses in infection control practices. During an observation, a laundry aide was seen distributing clean laundry from an uncovered linen cart in a resident hallway. Both the laundry aide and the laundry supervisor were unaware that the linen cart was required to remain covered at all times during transport and distribution, contrary to facility policy. The Director of Nursing confirmed that the cart should have been covered to prevent cross-contamination and unauthorized access to residents' clothing. Additionally, a nurse did not perform proper hand hygiene during wound care for a resident with a stage 4 pressure ulcer. The nurse failed to wash or sanitize hands after removing gloves and before donning new gloves while providing wound care. During the same episode, the resident’s wound was left uncovered and came into contact with a visibly soiled brief when the resident was repositioned. Both the nurse and the Assistant Director of Nursing acknowledged that these actions were not in accordance with infection control protocols and could lead to contamination of the wound. The resident involved had significant medical conditions, including a stage 4 pressure ulcer, severe chronic kidney disease, and vascular dementia. Physician orders required specific wound care procedures, including cleansing, application of dressings, and maintaining a sterile environment. The facility’s own policies on infection prevention, hand hygiene, and wound management outlined the need for proper handling of linens, consistent hand hygiene, and protection of wounds from contamination, all of which were not followed during the observed incidents.