An LPN failed to follow infection control practices during medication administration when she dropped a pill into the med cart, picked it up with her bare hands, returned it to a stock medication bottle used for other residents, recapped the bottle, and placed it back in the cart. The LPN confirmed the event and stated she probably should not have done that.
Staff failed to follow infection control practices during trach care and wound care by not performing hand hygiene between dirty and clean tasks and by not changing gloves appropriately. Staff also failed to follow contact precautions for a resident with MRSA and C. diff history when delivering meal trays without PPE or hand hygiene. In addition, the facility’s Legionella water management program was incomplete and lacked required monitoring, control, and response elements.
Failure to Use Required PPE for Enteric Precautions: Staff entered a resident’s room without hand hygiene or the required PPE while the resident was on enteric precautions for a potential C. difficile infection. CNA5 and CNA6 entered without following the posted precautions, and CNA5 later provided care wearing only gloves and did not perform hand hygiene when leaving the room. Interviews showed staff were unaware of the precautions or had not been informed of the requirements.
Soiled Linen Not Bagged Before Transport. The facility failed to follow its laundry and linen policy for handling soiled linen. An observation showed a Laundry Worker pushing a covered bin to collect soiled linen, then entering the soiled utility room where carts were overflowing and most linen in the bin was unbagged, including items soiled with feces and urine. The worker stated soiled linen should have been placed in plastic bags before leaving resident rooms and that it is often thrown into bins without bagging.
A facility failed to maintain proper laundry disinfection when the laundry boiler was malfunctioning and wash temperatures were only 62 to 65 degrees Fahrenheit, while staff used Oxi-Clean in loads and were unsure of the required hot water temperature. The facility also failed to ensure proper hand hygiene and PPE use during med pass: an LPN touched a resident and administered oral meds and eye drops without appropriate glove changes and hand hygiene, and another LPN administered insulin after handling room surfaces with the same gloves.
Surveyors found that washer filters were heavily soiled with lint and debris on all observed machines, despite manufacturer instructions and a label on the equipment requiring daily cleaning. The Laundry Supervisor stated that laundry staff did not maintain the filters and that maintenance was responsible, while the Maintenance Supervisor reported the filters were typically cleaned three times per week and that no documentation was kept to verify cleaning in accordance with manufacturer guidelines.
A resident with a Stage II sacral pressure injury received wound care during which an LPN failed to follow the facility’s Enhanced Barrier Precautions and dressing change policies. The LPN performed a sacral dressing change without donning a gown, even though the facility’s EBP policy requires gown and glove use for high-contact activities such as wound care. During the procedure, the LPN used a marker from her pocket to label the dressing and did not clean the bedside table or the marker afterward, despite policy requirements for maintaining a clean field and cleaning the bedside stand. In an interview, the LPN stated she forgot to wear the required PPE and confirmed that staff receive PPE-related training.
Staff failed to follow infection control protocols during medication administration and did not consistently implement Enhanced Barrier Precautions for two residents requiring them. This included a nurse using her fingers to handle medications without hand hygiene, placing an insulin pen on bed linens, and staff not wearing gowns during IV administration and incontinent care, despite clear EBP signage and policies.
A Laundry Aide was observed handling soiled linen and clothing without wearing gloves, contrary to facility policy requiring PPE use. The aide collected, tied, and replaced soiled linen bags with bare hands across multiple units, and both the Laundry Manager and Administrator confirmed that gloves should have been worn during these tasks.
Staff did not follow infection control protocols for two residents: one requiring Enhanced Barrier Precautions due to MDRO colonization, where staff provided incontinence care wearing only gloves and not gowns as required, and another receiving oxygen therapy, where a CNA reapplied oxygen tubing that had fallen on the floor without replacing it. These actions were contrary to facility policy and confirmed by interviews with staff and leadership.
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