F0880

E

Failure to Clean Reusable Equipment and Maintain Clean Linen Storage

Hamilton, Ohio Survey Completed on 03-24-2026

Penalty

No penalty information released

Summary

The deficiency involves failures in infection prevention and control related to reusable equipment cleaning and linen handling. One resident with sepsis, sarcoid myocarditis, an indwelling urinary catheter, and Klebsiella pneumoniae was on enhanced barrier precautions and contact precautions. Another resident with onychogryphosis and moderately impaired cognition was on enhanced barrier precautions due to a suprapubic catheter. During observation, an LPN obtained vital signs, including pulse oximetry, thermometer, and blood pressure measurements, from the first resident and then from another resident without cleaning the reusable equipment between residents. The LPN removed her gown and gloves and, when attempting to dispose of them in a red biohazard bin where the bag had fallen, reached into the bin with bare hands despite multiple dirty gowns being present, and later confirmed she should have worn gloves and cleaned the equipment between residents.

Additional observations on the F Hallway showed improper linen storage and proximity of soiled items to clean linen. A three-tier linen cart was observed with its front cover flap left open, exposing all towels and gowns to the air; a CNA confirmed the flap should always be down covering the linen. Later, the housekeeping supervisor observed a dirty white towel with brown spots placed on top of the clean linen cart and a dirty bag on the floor directly next to the linen cart containing gloves and a gown, and confirmed these findings. The DON confirmed that staff should be cleaning all reusable equipment between residents. Policy reviews showed that facility infection control policies required gloves when there is potential contact with blood or body fluids and required that reusable equipment not be used for another resident until appropriately cleaned and reprocessed.