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Based on policy and procedure review, observations and staff interview, the facility staff failed to assure safe infection control practices by failing to wear gloves when handling soiled/dirty linens for 2 of 2 observations.

Findings Included:

Review on 02/11/2021 of the facility policy and procedure titled "Infection Control: Linen" effective date 12/01/2017 revealed "HANDLING SOILED LINENS...Soiled linens will be handled in a manner to prevent the spread of infection. Procedure ...B. Gloves are worn when handling soiled linen. ..."

1. Observation on 02/10/2021 at 1030 revealed housekeeper #1 picking up soiled linen that had fallen off the top of the soiled linen bin onto the cement walkway outside of the rehab/residential buildings. The observation revealed housekeeper #1 was picking up the soiled linen with ungloved hands and placing into the soiled linen bin. Observation of housekeeper #1 revealed she was wearing a facemask but the facemask was underneath her chin and was not covering her nose or mouth. Observation revealed housekeeper #1 was in the presence and having conversations with unmasked facility patients.

Interview on 02/10/2021 at 1130 with the Infection Control Nurse revealed all staff handling dirty/soiled linens were expected to wear gloves. Interview revealed the facility housekeeping staff failed to follow the facility policy.

2. Observation on 02/11/2021 at 1200 revealed housekeeper #2 was pushing/pulling a dirty trashcan, dirty/soiled linen bin and clean supply cart in the hallway near the Detox unit dining room. Observation revealed housekeeper #2 had her ungloved hands inside the rim of the soiled linen bin (large trashcan) and her hands were making contact with the soiled linens.

Interview on 02/10/2021 at 1130 with the Infection Control Nurse revealed all staff handling dirty/soiled linens were expected to wear gloves. Interview revealed the facility housekeeping staff failed to follow the facility policy.

NC00174039, NC00174058, NC00174059, NC00174145