Failure to Sanitize Monitoring Device Between Residents
Penalty
Summary
During a medication administration task, a Registered Nurse (RN) failed to clean a portable monitoring device between its use on two residents. The RN used the device to take the vital signs of one resident and then proceeded to use it on another resident without sanitizing it in between. The RN admitted to being stressed and forgetting to clean the device, which is a required procedure to prevent cross-contamination between residents. The facility's Infection Preventionist (IP) confirmed that the staff had been trained to use purple top wipes to sanitize equipment, following the manufacturer's guidelines for drying and contact times. However, the RN involved had not signed the recent in-service training on this procedure. The Director of Nursing (DON) reiterated the expectation that all equipment should be cleaned between uses to prevent cross-contamination, as outlined in the facility's policy and CDC recommendations.
Plan Of Correction
Preparation and/or execution of this plan does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth on the statement of deficiencies. This plan of correction is prepared and/or executed solely because it is required. (a) Immediate action(s) taken for the resident(s) found to have been affected include: The monitor was Residents #98 and #1 received a skin check and there was no evidence of Inservice for RN D on proper monitor by IP nurse. (b) Identification of other residents having the potential to be affected was accomplished by: The facility has determined that all residents have the potential to be affected. All monitors were. (c) Actions taken/systems put into place to reduce the risk of future occurrence include: Starting on all licensed and certified nursing staff (RNs, LPNs, and C.N.A.s) were educated in Prevention and Control Policy, proper of the monitor, and their roles in preventing the spread of communicable and licensed and certified nursing staff (RNs, LPNs, and C.N.A.s) will be in-service by. Any licensed and certified nursing staff (RNs, LPNs, and C.N.A.s) not in-serviced by this date will be in-serviced prior to their next scheduled shift. We have no Agency staff currently. All newly hired licensed and certified nursing staff (RNs, LPNs, and C.N.A.s) will be in-service by the ADON during their orientation. (d) How the corrective action(s) will be monitored to ensure the practice will not: The IP nurse or designee will observe 2 staff 3 times a week for proper monitor for of 2 weeks then 2 staff twice weekly for 2 weeks then 2 staff monthly for up to 3 months. Any deficient practice found during the audits will be corrected immediately by the IP nurse or designee and/or corrective action done as appropriate. This plan of correction will be monitored at the QAPI meeting until such time consistent substantial compliance has been met. The IP Nurse will report the audit findings in the QAPI meeting. (e) The date of compliance is.