Infection Control and Laundry Deficiencies Compromise Resident Safety
Penalty
Summary
The facility failed to maintain and follow its infection prevention and control program on two of three units, resulting in lapses in hand hygiene, improper use of personal protective equipment (PPE), and inadequate cleaning of shared equipment. Specifically, a certified nurse aide (CNA) did not change gloves or perform hand hygiene after emptying a resident's indwelling urinary catheter and before providing incontinence care. The same CNA also failed to clean a shared shower chair after use, leaving it visibly soiled with stool before it was placed outside the resident's room for use. The resident involved had an indwelling urinary catheter and wounds, and was on enhanced barrier precautions (EBP), as indicated by signage on the door. Staff interviews confirmed that these actions were contrary to facility policy and infection control expectations. Additionally, the facility's main water heater was broken, resulting in laundry being washed at temperatures significantly below the recommended threshold for effective sanitation. The laundry aide reported that the water temperature during wash cycles was only sixty-eight degrees Fahrenheit, well below the CDC-recommended 160 degrees Fahrenheit for hot-water washing. As a result, the facility resorted to laundering some resident clothing and linens in the rehabilitation area, which was not equipped with industrial washers and dryers and lacked proper infection control or isolation measures. There was also no physical barrier separating the laundry area from resident spaces, further compromising infection prevention. Interviews with staff, including the infection preventionist, director of nursing, nursing home administrator, and laundry aide, confirmed awareness of the deficiencies. Staff acknowledged that the facility's infection control and laundry practices did not meet regulatory standards, and that the lack of functioning equipment and proper procedures contributed to the failure to provide a safe, sanitary, and comfortable environment for residents.