Infection Control Deficiencies: Improper Linen Handling, Equipment Cleaning, and Precaution Implementation
Penalty
Summary
The facility failed to implement and maintain effective infection prevention and control measures, as evidenced by multiple observed deficiencies. Dirty bed linen was found piled on the hallway floor outside a resident's room, rather than being bagged and removed from the resident's room as required by infection control protocols. A CNA confirmed that this practice was not in accordance with facility policy, which mandates that soiled linen should not be placed on the floor to prevent the spread of infection. Additionally, an LPN was observed using a glucometer on multiple residents without cleaning it between uses. The LPN admitted to not disinfecting the device after each use, despite having access to approved disinfectant wipes in the medication cart. This failure to clean shared medical equipment between residents increases the risk of cross-contamination and infection transmission. Further deficiencies were noted in the performance of sterile procedures and the implementation of Enhanced Barrier Precautions (EBP). A respiratory therapist did not maintain sterile technique during trach care, including failing to perform hand hygiene, improperly donning sterile gloves, and contaminating sterile supplies. Several residents with wounds, tracheostomies, or other conditions requiring EBP did not have appropriate precautions or care plans in place upon admission, as confirmed by the DON. These lapses in infection control practices were identified through medical record review, staff interviews, and direct observation, affecting multiple residents and potentially placing all residents at risk.