Infection Control Failures in Hand Hygiene and Linen Handling
Penalty
Summary
Surveyors identified deficiencies in the facility’s infection prevention and control program related to hand hygiene and linen handling. The facility’s hand hygiene policy, dated 12/15/25, required staff to perform hand hygiene between resident contacts, after handling contaminated objects, and before and after handling clean or soiled linens. During observation on the 100 hall, Laundry Aide-G (LA-G) delivered clothing to multiple residents’ rooms, including a resident on Enhanced Barrier Precautions (EBP), without performing hand sanitization between rooms. After exiting each room, LA-G placed used hangers back into the laundry cart and then retrieved additional clothing from the same cart for the next resident without using the alcohol-based hand rub that was available on the cart, contrary to facility policy and LA-G’s own acknowledgment of the requirement. Additional observations showed that the facility did not ensure laundry was transported in a sanitary manner. The infection prevention and control policy for linens required that laundry staff handle, store, process, and transport linens to prevent the spread of infection. However, LA-G was observed carrying a stack of clothing protectors cradled against their shirt while moving from the laundry area through the dining room and into another hallway. In an interview, the DON confirmed that clothing and linens were expected to be carried away from the uniform to prevent potential cross-contamination, indicating that this method of transport did not comply with facility policy. Surveyors also found failures in hand hygiene practices during medication administration and topical treatment for a resident. Resident 17’s record showed multiple diagnoses, including hypothyroidism, diabetes mellitus, basal cell carcinoma of the skin, candidiasis, urinary tract infections, and excoriation (skin-picking) disorder. During a medication pass, LPN-E did not perform hand hygiene between glove changes and applied topical medications to Resident 17 without changing gloves or performing hand hygiene after touching the wheelchair, medication cart, and tablet used for charting. Facility hand hygiene policy stated that glove use does not replace hand hygiene and required hand hygiene before donning gloves, immediately after removing gloves, after handling contaminated objects, and when moving from a contaminated body site to a clean body site. The Infection Preventionist confirmed that staff were expected to perform hand hygiene after removing dirty gloves and before donning clean gloves, which did not occur in this instance.
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