Infection Control Deficiencies in Hand Hygiene and Equipment Cleaning
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by multiple instances of staff not adhering to hand hygiene protocols during wound care and medication administration. Specifically, a Licensed Practical Nurse (LPN) did not perform hand hygiene after removing soiled gloves while providing wound care to a resident with an unstageable pressure ulcer and type 2 diabetes mellitus. This lapse in protocol was acknowledged by the LPN, the Infection Prevention (IP) Nurse, and the interim Director of Nursing (DON), all of whom recognized the potential for contamination and increased infection risk. Additionally, during medication administration, an LPN was observed handling medications with bare hands after they fell onto the medication cart, and failing to perform hand hygiene between administering medications to different residents. The LPN admitted to insufficient training and acknowledged the importance of hand hygiene to prevent infection spread. The IP Nurse and interim DON reiterated the expectation for staff to follow infection control procedures, including hand hygiene and proper handling of medications. The facility also lacked specific guidelines for cleaning reusable resident-care equipment, as observed when an LPN used a reusable electronic wrist blood pressure cuff on multiple residents without cleaning it between uses. The IP Nurse and interim DON expressed expectations for cleaning equipment to prevent infection transmission, but the LPN indicated a lack of instruction on this practice. The Administrator confirmed the expectation for staff to adhere to infection control policies to prevent the spread of infection.