Infection Control Failures in Disinfection, Precaution Signage, and PPE Use
Penalty
Summary
Nursing staff failed to properly disinfect a glucometer after use on three residents. The staff used Super Sani-Cloth Germicidal Disposable Wipes, which contain isopropyl alcohol and quaternary ammonium compounds, instead of the manufacturer-recommended hospital-approved germicidal bleach products. The infection preventionist confirmed that the facility used these wipes, which do not contain bleach, for glucometer disinfection. Manufacturer guidelines specifically require the use of EPA-registered bleach products for cleaning the glucometer, but this protocol was not followed. The facility did not implement its own infection control policies regarding the posting and accuracy of infection control precaution (ICP) signage for residents. In several cases, the signage on residents' doors did not match the current physician orders or the residents' actual precaution status. For example, one resident had a contact precautions sign posted despite not having an active order for contact precautions, while another resident had enhanced barrier precautions (EBP) signage posted when the order was for contact precautions due to a multidrug-resistant organism. Staff interviews revealed a lack of knowledge about the different types of ICPs and the reasons for their use, and attendance records showed that not all staff had received required training on these precautions. Additionally, an Emergency Medical Technician Transport (EMTT) staff member failed to remove personal protective equipment (PPE) and perform hand hygiene after providing care to a resident under enhanced barrier precautions. The EMTT exited the resident's room still wearing gown and gloves and did not clean his hands, contrary to facility policy and posted instructions. Both the EMTT and a licensed nurse acknowledged that PPE should have been removed and hand hygiene performed before leaving the room. The facility's policies and CDC guidelines require proper disposal of PPE and hand hygiene to prevent the spread of infection.