Infection Control Deficiencies in Medication Administration and Linen Handling
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program as evidenced by multiple observed deficiencies. During a medication administration observation, an LVN did not disinfect a metal tray used to transport medications between two residents. The tray was placed on surfaces in both residents' rooms and on the medication cart without being cleaned between uses. The LVN acknowledged that the tray should have been disinfected between residents to prevent disease transmission but stated that it was forgotten due to nervousness. Facility policy required all equipment to be cleaned with disinfectant wipes before and after use on residents, and the DON confirmed that the policy was not followed in this instance. Additionally, the facility did not ensure that mobile linen carts were covered with non-permeable material. Observations revealed that several linen carts were covered with permeable mesh material, both in resident care areas and in the laundry department. Staff, including the Infection Preventionist, District Manager, and Account Manager, acknowledged that the covers should be non-permeable to prevent environmental contaminants from settling on clean linens. The Administrator explained that there was a mistake in the ordering process for new covers, resulting in the continued use of inappropriate mesh covers. A further deficiency was observed in the laundry room, where a staff member's personal water container was found inside a linen cart next to clean linens. Both the Account Manager and Infection Preventionist confirmed that food and drink are not permitted in the clean laundry room to prevent contamination of linens. Facility policies reviewed indicated that maintaining a safe, sanitary environment and preventing cross-contamination are primary responsibilities for all staff. These observed practices were inconsistent with the facility's infection control policies and had the potential to contribute to the spread of communicable diseases and infections among staff and residents.