Failure to Maintain Infection Control Practices and Hand Hygiene
Penalty
Summary
The facility failed to maintain infection prevention and control practices to prevent the spread of COVID-19 and did not ensure staff performed proper hand hygiene during incontinence care. Sixteen residents tested positive for COVID-19 within a two-week period, and records showed that these residents had physician orders for droplet isolation precautions. However, observations revealed that required signage indicating isolation precautions was missing from the rooms of residents who tested positive, and staff confirmed that these signs should have been posted to alert staff and visitors to use personal protective equipment (PPE). Additionally, the facility did not separate soiled linens from residents with COVID-19 from those without, despite staff concerns about cross-contamination. Laundry staff and CNAs reported that all soiled laundry was mixed together and placed in the same receptacle, and biohazard bags or other methods to differentiate contaminated laundry were not used. This practice was inconsistent with CDC guidance and the facility's own policies, which require clear identification of contaminated laundry to ensure safe handling. Further, staff failed to adhere to hand hygiene protocols during resident care. During incontinence care for a resident, a CNA did not perform hand hygiene before donning gloves, after glove removal, or between tasks, and handled both the resident’s personal items and bed linens with contaminated gloves. The facility’s policy and CDC guidelines require hand hygiene before and after glove use and after contact with potentially contaminated surfaces, but these procedures were not followed during the observed care.