Infection Control Deficiencies in Monitoring, Medication Administration, and PPE Use
Penalty
Summary
Surveyors identified deficiencies in the facility's infection prevention and control practices involving two residents. In one instance, a Licensed Practical Nurse (LPN) failed to properly dispose of used blood glucose monitoring supplies, including a lancet, test strips, and used pads, by placing them in the regular garbage can in the resident's room instead of a sharps container. Additionally, the LPN did not clean the top of the insulin vial with an alcohol wipe before extracting medication with a needle syringe. The LPN later admitted to forgetting to clean the vial and was unsure about the correct disposal of unused supplies taken into a resident's room. Another deficiency was observed during care for a resident who required Enhanced Barrier Precautions (EBP) due to the presence of a medical device. The LPN providing care did not don a gown as required by EBP protocols, although gloves were used. The used care supplies were discarded in a biohazard bag and placed in the appropriate bin outside the room, but the omission of the gown was inconsistent with the facility's policy and the resident's care plan, which specified the use of PPE including gloves and gown for residents on EBP. Both residents involved had significant medical needs. One resident required regular blood glucose monitoring and insulin administration, while the other had a medical device and was at risk for infection, necessitating EBP. The facility's own policies and staff interviews confirmed that the observed practices did not align with established infection control standards, including the use of PPE and proper disposal of potentially infectious materials.
Plan Of Correction
F 880 F 880 F 880 1. The involved nurses were in-serviced by the Director of Nursing on the importance of preventing the spread of via instruction of proper place to dispose of used Accu-Chek supplies, wiping vial before drawing the desired units, and wearing PPE while providing care. 2. The DON implemented a performance improvement project with the nurse causing repeat citation for one month on control. 3. On 9 2025, an in-service was done by the DON with all nurses to ensure that everyone is reminded of the proper disposal of used Accu-Chek supplies as well as their role in preventing and controlling in the building. The DON demonstrated techniques through exercises of the proper way to prevent the spread of. One on one return demonstration was conducted. DON and nursing supervisor observed compliance by each nurse. 4. D.O.N or designee will do some extra shadowing of the nurses involved to monitor the quality of their control practices. 5. Nursing supervisor will do random checks weekly to monitor for compliance for the next 3 months. 6. Findings will be discussed monthly in QA meetings until substantial compliance has been achieved. F 880 F 880 F 880