Failure to Follow Infection Control Practices for Equipment Disinfection and Hand Hygiene
Penalty
Summary
The facility failed to ensure proper infection prevention and control practices regarding the cleaning and disinfection of reusable medical equipment and hand hygiene during resident care. In one instance, a nurse used shared scissors for a resident's care and cleaned them with an alcohol pad after use, rather than using the EPA-approved disinfectant as required by facility policy. The scissors were confirmed to be shared among staff, and the standard disinfection process described by staff did not align with the facility's infection control policy. The resident involved had a history of stroke, diabetes, seizure disorder, and a recent wound infection, and required enhanced barrier precautions due to a urinary catheter and a wound dressing change. In another instance, staff failed to perform appropriate hand hygiene and glove changes during a dressing change for a resident with a stage 4 open wound in the coccyx area. The nurse changed only one glove after cleaning a bowel-soiled area and did not perform hand hygiene before proceeding with the wound dressing, resulting in possible cross-contamination. The infection preventionist confirmed that both gloves should be changed and hands washed before continuing with the dressing change, and that failure to do so can cause cross-contamination. The resident involved required extensive assistance with activities of daily living and had enhanced barrier precautions in place due to the wound.