Multiple Infection Control Lapses in Linen Handling, PPE Use, Wound Care, Glucometer Disinfection, Medication Technique, and Urinal Placement
Penalty
Summary
The deficiency involves multiple failures in the facility’s infection prevention and control practices by several staff members in different care processes. A laundry aide transported clean clothes on a rolling rack that was not fully covered, contrary to facility expectations and CDC guidance for linen transport. During transport, the linen cover fell to the floor, and the aide picked it up and placed it back on top of the rack containing clean clothes instead of treating it as soiled and sending it to dirty laundry. The laundry manager and the infection preventionist both stated that clean linens and clothes were expected to be fully covered during transport and that any linen that touched the floor was considered soiled and should be placed in dirty laundry. Another deficiency occurred in the use of PPE for a resident on droplet precautions. An LPN entered a droplet precaution room wearing a gown and gloves but only had prescription eyeglasses on and did not use required eye protection such as a face shield or goggles, despite signage outside the room indicating that eye protection was required. The LPN stated they were unsure if prescription eyeglasses counted as PPE. The infection preventionist and the DON both stated that prescription eyeglasses were not considered PPE and that staff were expected to wear appropriate eye protection when caring for residents on droplet precautions. Additional infection control failures were identified during wound care and medication-related procedures. A nurse practitioner and an RN performed wound care on a resident with a sacral pressure injury requiring dressing changes three times a week, wearing only gloves and no gowns, even though they acknowledged that wound care required Enhanced Barrier Precautions and that gowns should have been worn. For another resident with orders for blood glucose checks before meals and at bedtime, an LPN cleaned a shared glucometer with an alcohol wipe instead of disinfecting it with Sani-cloth or bleach-based wipes between uses, contrary to facility policy and infection control standards. The same LPN also prepared and administered a Liraglutide injection using a pen device without wiping the rubber stopper with an alcohol swab before attaching a new needle, despite manufacturer instructions requiring this step and facility expectations for antiseptic technique. A further deficiency involved improper handling of a resident’s personal care item in relation to food service. A resident’s urinal, filled with urine, was observed on the bedside table next to the resident’s meal tray. A CNA confirmed that the urinal should not have been on the table next to the meal tray and that it should have been emptied. The infection preventionist and the DON both stated they did not expect a urine-filled urinal to be placed next to a meal tray and that it should have been emptied and kept away from the bedside table.
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