Inadequate Infection Control During Incontinent Care, Shower Room Cleaning, and Linen Handling
Penalty
Summary
The deficiency involves the facility’s failure to maintain an effective infection prevention and control program in multiple areas of care and environment. For one cognitively intact female resident with dementia, anxiety, depression, diabetes mellitus, atrial fibrillation, bladder incontinence, impaired mobility, and an ADL self-care deficit, a CNA provided incontinent care without adhering to proper hand hygiene and glove use. During the observed episode, the CNA loosened and rolled the soiled brief under the resident, wiped fecal smears from the buttocks, and then, without changing gloves or performing hand hygiene, tucked a clean brief underneath, removed the soiled brief, applied the clean brief, repositioned the resident, straightened the gown, and touched clean linens while still wearing the contaminated gloves. The CNA later acknowledged she should have performed hand hygiene and changed gloves when moving from dirty to clean tasks and that failure to do so could result in cross contamination and infection. The facility also failed to maintain cleanliness and proper handling of soiled items in a communal shower room on one hall. An unoccupied shower room was observed with four wet towels spread on the floor, two soiled wet washcloths hanging from the shower stall railing, and a lidded trash bin that could not close due to overflowing trash, with a folded gown placed on top of the lid. Nursing staff on the shift reported that baths or showers were not scheduled for that shift, stated they had not assisted residents with showers, and indicated they had no knowledge of the shower room being used. Staff interviewed stated that used supplies should have been picked up and the shower room cleaned after use, and that dirty supplies should be picked up and properly disposed of to prevent cross contamination. Additionally, the facility did not ensure proper handling and storage of clean linens. A linen cart on one hall was observed uncovered, and the CNA assigned to that area stated she may have become busy and forgotten to close the cover. She acknowledged that the linen cart should remain covered to prevent cross contamination and decrease the chances of residents getting an infection. Facility policies reviewed, including the perineal care policy and the infection control plan, required appropriate glove use, hand hygiene before and after glove use, proper disposal of soiled items, and handling and storing linens in a manner that prevents the spread of infection. Interviews with the RN, DON, and Administrator confirmed expectations that staff follow proper procedures for incontinent care, shower room cleanliness, and keeping linen carts covered to prevent cross contamination and infection.
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