Failure to Adhere to Infection Control Protocols and Contact Precautions
Penalty
Summary
The facility failed to ensure proper infection prevention and control practices in several instances involving the use of shared medical equipment, adherence to contact isolation protocols, and education of staff and visitors regarding transmission-based precautions. In one case, a registered nurse disinfected a shared glucometer with an alcohol pad after use on a resident with diabetes and chronic kidney disease, despite the availability of EPA-approved disinfectant wipes and facility protocols requiring their use. The nurse believed alcohol pads were acceptable based on previous pharmacy guidance, but both the Director of Nursing and Infection Preventionist later confirmed that only EPA-approved wipes with a specified contact time were appropriate for disinfecting shared glucometers to prevent cross-contamination. In another instance, staff failed to follow contact isolation procedures for a resident on precautions for possible Clostridium difficile infection. Despite clear signage and the availability of personal protective equipment (PPE) at the room entrance, multiple staff members entered and exited the resident's room without donning the required PPE or performing hand hygiene with soap and water, as mandated for C. difficile precautions. Staff later acknowledged that they had not paid attention to the isolation signage and were aware that proper handwashing and PPE use were required but had not been performed. Additionally, the facility did not ensure that visitors and staff consistently adhered to contact precautions for a resident with a wound infection. A visitor entered and remained in the resident's room without wearing the required gown and gloves, stating they were unaware of the need for PPE. The facility's care plan and policies required education for visitors and documentation of such education, but there was no evidence in the medical record that the visitor had been informed about the precautions. Furthermore, a licensed practical nurse was observed entering the same resident's room without donning PPE, despite acknowledging the necessity of these measures to prevent infection spread.