Infection Control Lapses During Resident Care
Penalty
Summary
The facility failed to maintain appropriate infection prevention and control practices during wound care for two residents. During an observation, the Unit Manager and Director of Nursing (DON) were seen performing wound care on a resident without adhering to proper hygiene protocols. The DON retrieved a pair of scissors from a care cart without cleaning them and placed them on a clean barrier. The Unit Manager used these scissors to cut foam dressings for the resident's skin. Additionally, the DON handled a sock from the floor and placed it on the resident without changing gloves or performing hand hygiene before touching the clean dressing. In another instance, a Registered Nurse (RN) was observed preparing to administer medication via a feeding tube for a resident. The RN did not sanitize her hands before putting on gloves and continued to handle medication supplies after dropping them on the floor. She labeled a medication container and connected new tubing to the resident's feeding tube without changing gloves or sanitizing her hands throughout the process. The facility's lack of specific care policies and failure to adhere to existing infection control protocols contributed to these deficiencies. The observations revealed lapses in hand hygiene, improper handling of medical equipment, and inadequate use of personal protective equipment, which are critical components of infection prevention and control in a healthcare setting.
Plan Of Correction
F 880- Prevention & Control 1: What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice; A. Resident #1 and 6 have had no negative outcomes. 2: How you will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken; A. A complete audit of residents with care and feeding was done to ensure appropriate orders and interventions are in place and any abnormal findings were corrected. 3: What measures will be put into place or what systematic changes you will make to ensure that the deficient practice does not recur; A. The Director of Nursing and Unit Managers were educated on control and proper change procedure. B. License nurses were educated on proper feeding administration and change procedures/techniques. C. Competencies for changes are completed on current license nurses and will be completed on any new license nurses hired. D. Nursing Managers will do weekly rounds to ensure appropriate treatment and healing of is followed. E. Education of staff on the components of F880 this will be provided annually and upon new hire orientation. 4: How the corrective action(s) will be monitored to ensure the deficient practice will not recur, i.e., what quality assurance program will be put into place. A. The Director of Nursing/Designee will do random audits of care, and feeding administration to ensure proper procedure/techniques are being utilized weekly for four weeks then monthly for one quarter. B. The Director of Nursing/Designee will submit a report of findings to the Quality Assessment, Assurance and Compliance Committee monthly for one quarter.