Failure to Maintain Infection Control Program and Proper Cleaning Procedures
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by multiple observations of housekeeping staff not following proper cleaning and hand hygiene procedures. During cleaning of resident rooms, housekeeping staff were observed donning new gloves without performing hand hygiene, handling both clean and dirty items without changing gloves or sanitizing hands, and neglecting to disinfect high-touch surfaces such as call lights, door knobs, and grab bars. Additionally, staff placed contaminated items, such as trash cans, on already cleaned surfaces, leading to potential recontamination. Specific cleaning lapses included not disinfecting reusable cleaning equipment like toilet brushes after use, failing to clean side rails in resident bathrooms, and not sweeping the entire floor prior to mopping. Housekeeping staff also used the same gloves to handle both dirty cleaning rags and resident personal items, such as a juice cup, without changing gloves or performing hand hygiene in between tasks. These actions were inconsistent with both CDC guidelines and the facility's own policies on cleaning, disinfecting, and hand hygiene. Interviews with housekeeping staff and facility leadership confirmed awareness of the correct procedures, but staff admitted to forgetting or skipping steps such as cleaning high-touch areas and performing hand hygiene between glove changes. The infection preventionist and maintenance director both stated that gloves should be changed and hand hygiene performed between tasks, and that high-touch areas must be disinfected daily. Despite this, observed practices did not align with these expectations, resulting in a failure to prevent the development and transmission of infections within the facility.