Infection Control and Hand Hygiene Deficiencies
Penalty
Summary
The facility failed to adhere to CDC guidelines for hand hygiene, as evidenced by several observations. In the kitchen, handwashing sinks were located on one side of the wall, while paper towel dispensers were on the opposite side, leading to water drips on food preparation surfaces. This setup was confirmed by the Food Service Director. Additionally, during a medication pass, a Registered Nurse used the same glucometer on two residents without cleaning it between uses, contrary to the facility's procedure and manufacturer's instructions, which require disinfection before and after each use. Further observations revealed improper hand hygiene practices among staff. A Nursing Assistant was seen washing her hands without lathering soap and turning off the faucet with bare hands. Similarly, a Certified Nursing Assistant handled soiled linens, removed gloves, and washed hands improperly by not lathering soap for the recommended duration and using the same paper towel to turn off the faucet. An agency RN failed to use soap when washing hands after handling a trash can lid and cleaning a spill, citing a lack of soap, which was later found to be available. The facility's policy requires washing hands with soap for 20 seconds outside the stream of water and using a clean towel to turn off the faucet. Additionally, a Phlebotomist was observed carrying a urine specimen in a wet bag through the facility while wearing gloves, which is against the facility's protocol. The Phlebotomist acknowledged the need to place the contaminated bag into a clean one for proper transport. The Director of Nursing confirmed the necessity of appropriate hand hygiene and the correct handling of specimens. These observations highlight the facility's failure to implement effective infection prevention and control measures as per their policies and CDC guidelines.
Plan Of Correction
1/17/25 1. Corrective Action of Areas Affected: The facility completed re-inservicing, competency training, and observations on the specific nurses related to [R]cleaning and hand hygiene for residents #46 and #48. 2. Other Areas Affected: The Director of Nursing/designee has conducted re-inservicing, competency training, and observations for nurses, CNAs, and Dietary on proper hand hygiene techniques. The Director of Nursing/designee has conducted re-inservicing, competency training, and observations for licensed nursing staff related to glucometer cleaning. 3. Systemic Changes to Prevent Future Occurrences: Licensed nurses, CNA's, and Dietary staff have been re-educated by the Director of Nursing/designee on hand hygiene policies and procedures. Licensed Nursing staff have been re-educated by the Director of Nursing/designee on the manufacturers recommendations for cleaning of the glucometers after each use. 4. Monitoring of Corrective Action: The Director of Nursing/designee will observe 5 staff members' hand hygiene techniques weekly x4, then monthly x2. The Director of Nursing/designee will observe 5 nurses on the cleaning technique of glucometers after use weekly x4, then monthly x2. Results of the audit will be reported monthly to the Quality Assurance Improvement Plan Committee.