Multiple Infection Control Deficiencies Identified
Penalty
Summary
The facility failed to maintain proper infection control practices in several areas, as evidenced by direct observations, interviews, and review of facility policies and procedures. One incident involved a laundry rolling rack with clean residents' clothing being transported uncovered through hallways and left unattended, contrary to facility policy requiring clean linen to be covered during transport and storage. Staff verified that the linen should not have been left uncovered or unattended, acknowledging the lapse in infection control protocol. Another deficiency was identified in the management of a resident with unresolved scabies. Despite ongoing symptoms and treatment with Elimite cream and Ivermectin, the resident was not placed on contact isolation after the initial treatment failed, and there was no follow-up skin testing or consultation with a dermatologist. The facility also failed to notify the local public health department about the unresolved case, as required by both facility policy and public health guidelines. Interviews confirmed that the resident continued to have generalized, crusty rashes and increased itchiness, and that the public health nurse was not informed of the situation. Additional infection control breaches included a CNA using the same gown and gloves to provide care to two different residents, one of whom was on enhanced barrier precautions (EBP), which is against CDC standards and facility policy. Observations also revealed that a resident's indwelling urinary catheter drainage bag and another resident's negative pressure wound therapy tubing were both found touching the floor, which staff acknowledged should not occur to prevent contamination and infection. These findings were confirmed through interviews with staff and review of relevant medical records and facility policies.