Infection Control Deficiencies in Hand Hygiene, Glucometer Disinfection, and Medication Administration
Penalty
Summary
Staff failed to perform appropriate hand hygiene and glove changes during peri care for a resident with severe cognitive impairment and total incontinence. Two nurse assistants washed their hands and donned gloves before beginning care, but did not change gloves or wash hands after removing a soiled brief and cleaning the resident's peri area. They proceeded to place a clean brief and dress the resident without changing gloves or performing hand hygiene, only removing gloves and washing hands at the end of the process. The nurse assistants stated they only changed gloves or washed hands if there was visible stool, contrary to facility policy and infection preventionist guidance, which required glove changes and hand hygiene when moving from dirty to clean tasks. A shared glucometer was not cleaned and disinfected according to the manufacturer's instructions after use for blood sugar testing. An LPN used the glucometer for a resident with diabetes, then cleaned it with an alcohol wipe before returning it to the medication cart. The LPN stated this was her usual process, but the manufacturer's instructions required a two-step process: cleaning with detergent and then disinfecting with a validated bleach wipe, ensuring the device remained wet for the required contact time. The assistant director of nursing confirmed that shared glucometers should be disinfected with the appropriate wipes, and was unaware that a shared device was in use. During eye drop administration for a resident with moderately impaired cognition and multiple diagnoses, a trained medication aide did not wear gloves or perform hand hygiene. The aide used bare hands to hold the resident's eyelids open and administer the drops, repeating the process when the first attempt was unsuccessful. The aide acknowledged that gloves should be worn to prevent germ transmission but did not do so in this instance. Facility policy required staff to follow infection control procedures, including hand hygiene and glove use, during medication administration.