Infection Control Deficiencies: PPE Noncompliance, Improper Linen Handling, Mask Use, and Unsanitary CPAP Drying
Penalty
Summary
The facility failed to ensure proper infection prevention and control practices were followed in several instances involving the use of personal protective equipment (PPE), handling of soiled linens and clothing, mask use during a respiratory outbreak, and the sanitary drying of CPAP supplies. Staff did not consistently don required PPE, such as gowns and gloves, when providing care to residents on enhanced barrier precautions (EBP) and enhanced respiratory precautions (ERP). Specifically, a trained medication aide (TMA) was observed providing direct care to two residents requiring EBP without wearing a gown or gloves, despite signage on the door indicating the need for such precautions. The TMA stated she was unaware of the need for PPE as she did not see the signs. Additionally, the TMA did not use a face shield when required for a resident on ERP, incorrectly believing that eyeglasses were sufficient. The facility also failed to follow proper infection control practices regarding the handling of soiled linens and resident personal clothing. Used linens, towels, and clothing were observed left on the floor in the rooms of two residents on EBP, rather than being bagged as required. Staff interviews confirmed that placing soiled items on the floor was not appropriate and that items should be bagged to prevent contamination, especially in shared rooms. During a period when the facility was under outbreak status and masking interventions were in place, a clinical provider was observed multiple times in patient areas and common spaces without wearing a face mask. The provider acknowledged awareness of the mask policy but did not consistently comply, only donning a mask when observed by surveyors. Facility leadership confirmed that mask use was expected for all staff and providers during outbreak precautions. Additionally, a resident's CPAP supplies were repeatedly observed drying on a towel bar inside a shared bathroom, contrary to facility policy and staff expectations that such equipment should be dried in the resident's room to prevent contamination.