Infection Control Deficiencies in Medication Administration and Resident Hygiene
Penalty
Summary
The facility failed to maintain proper infection control practices during medication administration, as observed with one of the nurses. During the administration of medication to a resident, the nurse placed a glucometer and insulin pen on the resident's blanket instead of using a sanitized surface. The nurse admitted to usually using a table with a barrier but did not do so because the resident was using the table to eat. The Director of Nursing confirmed that the nurse should not have placed the medical equipment on the bed. Additionally, the facility did not ensure that residents were assisted with hand hygiene before meals. During meal observations on two units, several Certified Nursing Assistants failed to provide sanitizing wipes or assist residents with washing their hands before eating. Interviews with the staff revealed that they either forgot to provide the wipes or assumed someone else was responsible for the task. The Director of Nursing Services acknowledged that the staff should have provided sanitizing wipes or assisted with hand hygiene. Furthermore, a resident's urinary drainage bag was observed touching the floor, which is against the facility's urinary catheter guidelines. The resident, who was cognitively impaired and dependent on all activities of daily living, had a urinary catheter. Staff interviews confirmed that the catheter bag touching the floor is an infection control issue, as it could lead to backflow and introduce bacteria. The Director of Nursing stated that the incident was unintentional and resulted from the bed being in the lowest position, acknowledging it as a breach in infection control.
Plan Of Correction
Plan of Correction: Approved January 29, 2025 Element 1 - Facility policy titled Infection Prevention and Control Program was reviewed by DNS; no revisions needed. Licensed Practical Nurse # 1 was in-serviced by DNS on facility Infection Prevention and Control program. Licensed Practical Nurse # 1 was in-serviced by DNS on glucometer check process. Resident # 3 was assessed by DNS; no ill effects from deficient practice; resident stable. The facility policy titled Hand Hygiene was reviewed by DNS; no revisions needed. Certified Nurses Aides # 2, #3, #4, and #5 were in-serviced by DNS on Hand hygiene policy, specifically residents' hand hygiene prior to meals. Resident # 41, # 37, #72, #17, #54, and # 24 were assessed by DNS; no ill effects from deficient practice. The facility policy titled Urinary Catheter Guidelines was reviewed by DNS; no revisions needed. Resident # 4 was assessed by DNS; no ill effects from deficient practice. Licensed Practical Nurse # 3 was in-serviced on Urinary Catheter Guidelines policy. Element 2 - All residents had potential to be affected by the deficient practice. Element 3 - In-service for all Registered Nurses and Licensed Practical Nurses on facility Infection Prevention and Control program. In-service for all Registered Nurses and Licensed Practical Nurses on Urinary Catheter Guidelines policy. In-service for all Certified Nurse’s Aides on Hand hygiene policy, specifically residents' hand hygiene prior to meals. Audit tool was created and in place to monitor resident hand hygiene before meals weekly for 4 weeks, then monthly for 3 months, then quarterly. Audit tool was created and in place to monitor Licensed Practical Nurse process during resident fingerstick weekly for 4 weeks, then monthly for 3 months, then quarterly. Audit tool was created and in place to monitor resident catheter tubing and bag placement weekly for 4 weeks, then monthly for 3 months, then quarterly. Any deficient findings will be addressed immediately. Element 4 - The DNS/Designee will report all findings to the QAPI committee monthly for 3 months. Responsible Party: DNS/Designee.