Failure to Implement Infection Control Practices for Meal Service, PPE Use, and Soiled Linen Handling
Penalty
Summary
The facility failed to implement its infection prevention and control program as required by policy and regulation. For one resident with dysphagia, dementia, progressive multiple sclerosis, severe cognitive impairment, and a need for staff assistance with eating, staff did not provide a clean meal tray. Surveyors observed that after lunch carts arrived on the unit and staff began placing used trays into one of the carts, a certified nursing assistant (CNA) retrieved this resident’s untouched meal tray from the same cart that already contained soiled trays. The CNA then provided this tray and fed the resident at bedside. The LPN manager, Infection Preventionist, and Director of Nursing each stated that the tray should not have been retrieved from a cart containing soiled trays and that this practice posed an infection control concern and a risk for contamination and potential spread of infection. The facility also did not follow its Enhanced Barrier Precautions policy for a second resident who had malnutrition, Parkinson’s disease, several open wounds, severe cognitive impairment, and several unhealed pressure ulcers. The resident’s care plan and CNA Kardex documented that the resident was on enhanced barrier precautions, with interventions including wearing a gown and gloves during high-contact care. Despite a sign posted outside the room indicating enhanced barrier precautions, surveyors observed two CNAs repositioning the resident in bed while wearing only gloves and no gowns. The Infection Preventionist stated that failure to wear appropriate PPE during high-contact care posed a risk for contamination and potential spread of infection to other residents. In addition, the facility did not ensure proper handling of soiled linens in accordance with its policies. The facility’s policies required staff to wear gloves and impervious (waterproof) gowns or yellow precaution gowns when sorting soiled linen. However, in the designated laundry area, a laundry assistant reported that staff wore gloves and cloth aprons while sorting soiled laundry and that the aprons were laundered every few days. The Infection Preventionist examined the aprons and confirmed they were cloth and not impervious, and stated that sorting soiled laundry without an impervious gown posed a risk for contamination and potential spread of infection due to lack of protection against soak-through contamination. Leadership later stated they were unaware that staff were sorting soiled laundry wearing cloth aprons and that this practice was not sanitary.
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