Infection Control Program Deficiencies and Improper Linen Handling
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program as evidenced by incomplete and inaccurate infection control line lists for both residents and staff. The line lists were missing critical information such as last symptom dates, times, and return-to-work dates, which are required by facility policy and CDC guidance. Additionally, the facility did not provide requested COVID-19 testing results for staff on day 5 and day 7, and several entries for residents and staff lacked documentation of symptom resolution or removal from precautions. The Director of Nursing confirmed these omissions and acknowledged that the facility used the test date as day one instead of day zero, contrary to standard protocols. Direct care observations revealed lapses in infection control practices during resident care and linen handling. For one resident with multiple comorbidities, including diabetes and chronic kidney disease, an Assistant Director of Nursing placed a sheet that had been on the floor back onto the resident's bed and later covered the resident with it, despite the resident indicating it was saturated with urine. During peri-care, a CNA used only two washcloths for both the front and back areas, placed soiled washcloths directly on the bed without a barrier, and failed to change gloves or perform hand hygiene before handling clean items and assisting with a lift. Both the CNA and the Director of Nursing confirmed these practices, which were inconsistent with facility policy and training materials. Further, improper linen handling was observed during catheter care for another resident, where a CNA placed washcloths in a sink without sanitizing it first, instead of using a basin as required. The CNA and the staff development nurse both acknowledged that this was not in accordance with facility procedures. These observed actions and documentation failures demonstrate a lack of adherence to established infection control protocols, increasing the potential for transmission of communicable diseases among residents and staff.