Infection Control and Linen Management Deficiencies
Penalty
Summary
Staff failed to follow infection prevention and control practices during a wound dressing change for a resident with a pressure ulcer. The LPN did not perform hand hygiene before donning gloves, between glove changes, or after removing gloves, despite handling soiled dressings and clean supplies. The LPN also placed clean dressing supplies on an unclean tray table surface and used tape from her pants pocket, further breaching infection control protocols. The facility's policy required cleaning the work surface and performing hand hygiene before applying clean gloves, which was not followed. Observations over two consecutive days revealed that dirty linens were left on the floor and on surfaces in a shower area, and personal care items were improperly stored in the same area. The same linens and personal items remained in place from one day to the next, indicating a lack of timely removal and cleaning. In the laundry area, dirty linen bags were stored on the floor due to limited space and equipment breakdowns, and clean linens were stored in unsanitary conditions. Wall fans and ceiling exhaust fans blowing toward clean linen areas were found to be dirty, and the emergency linen supply was inadequate, lacking essential items such as washcloths, top sheets, pillowcases, blankets, bed pads, and bedspreads. Sinks in both the dirty and clean sides of the laundry were unclean and obstructed, with one sink cracked and used for storage of dry supplies, and the other surrounded by dust and debris. For a resident receiving tube feeding, the facility failed to ensure that the tube feeding was labeled correctly and discarded in a timely manner. The tube feeding bottle was found hanging without a date, time, or feeding rate, and the water bag and tubing had inconsistent labeling dates. Staff interviewed were unaware of the labeling discrepancies or how long the feeding had been hanging, despite facility policy requiring clear labeling of tube feeding systems with resident name, date, time, contents, rate of flow, and nurse's initials.