Infection Control Deficiencies During Medication Administration
Penalty
Summary
The facility failed to adhere to proper infection control practices during a medication administration observation. On December 17, 2024, an LPN was observed preparing medications for a resident without following appropriate hand hygiene protocols. After taking the resident's blood pressure, the LPN washed her hands for 15 seconds but found no paper towels available to dry them. She turned off the faucet with her bare hands and used a tissue to dry her hands without sanitizing them afterward. Later, the LPN prepared medications for another resident on Enhanced Barrier Precautions without performing hand hygiene and entered the resident's room without cleaning the blood pressure cuff. The LPN admitted to the surveyor that she should have used hand sanitizer after touching the faucet and acknowledged the risk of spreading germs by not cleaning the blood pressure cuff between residents. The LPN/Unit Manager and the LPN/Infection Preventionist confirmed that the LPN should have washed her hands after touching the faucet and cleaned the blood pressure machine between residents. The Director of Nursing also stated that the failure to clean the blood pressure cuff could pose an infection control issue. The facility's policies on hand hygiene and cleaning of reusable equipment were not followed, contributing to the identified deficiencies.
Plan Of Correction
1. Resident #33 and resident #49 had [R] as a result of the deficient practice of: a. LPN #1 who failed to properly perform hand hygiene after removing gloves. b. LPN #1 who failed to clean a NEXO cuff between residents. On 12/17/2024, Assistant Director of Nursing completed 1:1 education with LPN #1 on hand hygiene and disinfecting NJ Exec Order 26.4b1 cuff between residents. 2. All residents have the potential to be affected by these deficient practices. 3. On 12/17/2024, Infection Preventionist completed one on one education with LPN #1 on hand hygiene and proper infection prevention when donning and doffing Personal Protective Equipment (PPE) and disinfecting equipment between residents. Competency on hand hygiene was completed with nurse with satisfactory return demonstration. Additionally, education was initiated for all nurses on Hand Hygiene and proper infection prevention when donning and doffing PPE and disinfecting equipment between residents. Rounds and observations were completed to ensure staff were using proper hand hygiene when donning and doffing PPE and proper disinfecting of BP cuffs between residents. 4. Infection Preventionist will complete rounds weekly for 12 weeks to ensure all staff perform hand hygiene on proper infection prevention when donning and doffing PPE and disinfecting equipment between residents. The results of these audits will be reported to the QAPI committee monthly for 3 months.