Infection Control Failures in Linen Handling, Equipment Cleaning, and Barrier Precautions
Penalty
Summary
Facility staff failed to adhere to infection prevention and control protocols in several instances involving the handling of soiled linens, cleaning of respiratory equipment, and use of enhanced barrier precautions. Observations revealed that nursing assistants carried soiled linens and bedding against their bodies and clothing, contrary to facility policy, which requires soiled linen to be bagged and handled with minimal agitation to prevent contamination. Staff were seen carrying soiled items uncovered through hallways and placing soiled gowns under their arms while assisting residents, actions confirmed by both the staff involved and facility leadership as improper. Additionally, staff did not consistently clean and disinfect non-critical patient care equipment such as nebulizer kits and PAP (Positive Airway Pressure) machines. Multiple observations showed nebulizer kits with residual medication and facial oils left uncleaned on bedside tables after use for two residents. Similarly, a resident's BiPAP machine and mask were found with facial oils, water left in the humidifier, and missing filters over several days, despite orders and manufacturer guidelines requiring daily and weekly cleaning. Interviews with staff and a family member confirmed that cleaning was not performed as required. The facility also failed to implement enhanced barrier precautions during high-contact care activities for a resident with a urinary catheter. During catheter and incontinence care, staff did not wear gowns as mandated by facility policy for residents with indwelling medical devices. Staff interviews confirmed awareness of the requirement but acknowledged that enhanced barrier precautions were not used during the observed care.