Deficiencies in Infection Control and Isolation Precautions
Penalty
Summary
Surveyors identified deficiencies in the facility's infection prevention and control practices. In one instance, a resident placed on contact isolation for a staph infection had a biohazard waste receptacle for used personal protective equipment (PPE) located in the middle of the room, between the beds of two residents. This placement required staff to walk past the resident's bed and dresser to dispose of soiled PPE, rather than having the disposal container near the exit as required by facility policy and standard infection control practices. The infection preventionist confirmed that this setup constituted a break in isolation protocol, as it increased the risk of transmitting the organism to other residents. Another deficiency was observed during medication administration for a resident with diabetes and other medical conditions. An LPN performed a blood glucose check and administered an injectable medication without donning gloves, despite the potential for exposure to blood. The LPN also failed to sanitize his hands before and after the procedure and did not clean the glucometer before placing it back into the medication cart. The Director of Nursing confirmed that the facility's policy required the use of gloves and cleaning of equipment between residents, and acknowledged that the LPN did not follow these procedures. Facility policies reviewed by surveyors indicated that staff were required to wear gloves during procedures involving potential exposure to blood or body fluids, and to clean reusable equipment after each use. The observed failures to adhere to these policies during both isolation precautions and medication administration led to the cited deficiencies in infection prevention and control.
Plan Of Correction
F 880 A) What corrective action will be accomplished for these residents found to be effective: On Resident #56, biohazard waste receptacle for used PPE was moved to the appropriate location near the exit of the resident's room. On Resident #64, was assessed and no adverse side effects were noted at that time. On LPN A, received education from the ADON on appropriate handwashing, appropriate use of PPE, isolation precautions, and how to appropriately clean multi-use items. B) How will you identify other residents having potential to be affected and what corrective actions will be taken: All residents with isolation precautions or who require monitoring. On no other residents were able to be identified upon review of LPN A's assigned residents. On LPN A, received education from the ADON on appropriate handwashing, appropriate use of PPE, isolation precautions, and how to appropriately clean multi-use items. On the ADON, initiated education for all licensed nurses on appropriate handwashing, appropriate use of PPE, isolation precautions, and how to appropriately clean multi-use items. On biohazard waste receptacles in isolation rooms were moved to the appropriate location near the exit of the resident rooms. Staff have been educated on the appropriate placement of the waste receptacles. C) What measures will be put in place or what system change will be made to ensure this will not recur: On LPN A, received education from the ADON on appropriate handwashing, appropriate use of PPE, isolation precautions, and how to appropriately clean multi-use items. On the ADON, initiated education for all licensed nurses on appropriate handwashing, appropriate use of PPE, isolation precautions, and how to appropriately clean multi-use items. On staff, initiated education on handwashing, implementation of appropriate isolation precautions, and appropriate use of PPE. On biohazard waste receptacles in isolation rooms were moved to the appropriate location near the exit of the resident rooms. Staff have been educated on the appropriate placement of the waste receptacles. The Unit Managers, or designee, will randomly audit, 3 times a week, across all shifts, staff handwashing, implementation of appropriate isolation precautions, appropriate placement of biohazard waste receptacles, medication administration for appropriate use of PPE, and use and cleaning of multi-use items. Audits will be submitted to the DON weekly. Any identified problems will be addressed immediately. D) How the corrective action will be monitored to ensure the potential will not occur: The DON, or designee, will report the findings of the audits to the QA and QAPI committees monthly for 3 months, then quarterly for 4 quarters.