Infection Control Breaches in Resident Care, Laundry, and Wound Treatment
Penalty
Summary
The facility failed to maintain its infection prevention and control program as evidenced by multiple observed breaches in infection control practices. In one instance, a certified nursing assistant (CNA) placed a resident's urinal containing urine on top of the overbed table near uncovered cups of water and juice. The CNA then removed the urinal, discarded its contents, rinsed it, and returned it to the same location, all while wearing the same gloves. The CNA continued to use the contaminated gloves to move the overbed table and put socks on the resident, without performing hand hygiene or changing gloves. Both the CNA and the infection preventionist (IP) acknowledged that the urinal should not have been placed on the overbed table and that proper hand hygiene was not performed. Another deficiency was observed in the facility's laundry area, where a laundry aide's personal belongings, including a black backpack and jacket, were stored with clean linen in the clean linen room. Both the laundry aide and the housekeeping supervisor confirmed that personal items should not be stored with clean linen, as per facility policy. The administrator also verified that the clean linen area must be kept clean and free of personal belongings. Additionally, a licensed vocational nurse (LVN) failed to perform appropriate hand hygiene during wound care for a resident with a sacrococcyx pressure injury. The LVN was observed touching the resident's thigh after handling a trash can with the same gloves, removing gloves and donning new ones without hand hygiene, and completing the wound care procedure without changing gloves or performing hand hygiene between steps. The LVN acknowledged that proper infection control practices, including handwashing after touching dirty surfaces, were not followed. The director of nursing (DON) confirmed that the facility's policy requires hand hygiene and glove changes during such procedures.