Infection Control and PPE Deficiencies in Resident Care and Facility Operations
Penalty
Summary
Multiple deficiencies in infection prevention and control were observed throughout the facility. During wound care for two residents, staff failed to perform hand hygiene at critical points, such as after removing soiled gloves and before donning clean gloves, and did not use barriers for clean dressing supplies. In one instance, a staff member handled wound packing material that touched a soiled bedsheet before being placed into a resident's wound, and clean dressing tools were placed directly on potentially contaminated surfaces. Staff involved in these procedures acknowledged that hand hygiene should occur between dirty and clean processes but did not consistently follow this protocol during observed dressing changes. In the laundry area, staff did not use appropriate personal protective equipment (PPE) when sorting and loading dirty linens, as they were not required to wear clothing protectors to prevent contamination. Additionally, staff did not consistently sanitize all necessary parts of the washing machine, such as the interior rim of the door, before removing clean laundry. Staff responsible for these tasks indicated a lack of clear procedures and expectations regarding PPE use and cleaning protocols. The facility also lacked a comprehensive infection control program, as there was no documented facility and community-based infection control risk assessment available. The water management program was incomplete, missing key components such as specific control measures, corrective actions, contingency responses, procedures for confirming program effectiveness, and communication protocols. Staff were unaware of certain infection control interventions, such as Enhanced Barrier Precautions, and did not consistently follow posted instructions for PPE use during resident care.