Infection Control Deficiencies in Resident Care, Laundry Handling, and Water Management
Penalty
Summary
The facility failed to maintain proper infection control measures in three key areas. During incontinent care for a resident with severe cognitive impairment and bowel and bladder incontinence, a CNA did not remove soiled gloves or perform hand hygiene after providing peri care and before continuing to clean the resident's legs. The CNA confirmed during an interview that she did not change gloves or use hand hygiene, and the DON acknowledged awareness of infection control protocols but noted the CNA should have known better. In the laundry area, clean and soiled linens were not adequately separated. Soiled laundry was sorted on the unit and brought into the laundry room, then after washing and drying, clean laundry was transferred across a soiled area to a folding room. The laundry room lacked appropriate PPE such as gowns, gloves, or masks, and disinfectant was stored with clean items. The Infection Preventionist was not aware of the issue with clean linen passing through the soiled area. Additionally, the facility's water management program for Legionella was incomplete, lacking documentation of water flow, identification of potential pooling sites, and testing protocols, as confirmed by the Maintenance Director.