Failure to Adhere to Infection Control and Hand Hygiene Protocols
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by multiple staff not adhering to proper hand hygiene and equipment disinfection protocols during resident care. In one instance, a CNA provided incontinence care to a male resident with a history of infection and diabetes without performing hand hygiene before donning gloves, and again failed to sanitize hands when changing gloves between dirty and clean tasks. The CNA only performed hand hygiene after completing all care and handling trash, contrary to facility policy and infection control standards. During blood glucose monitoring for two residents with diabetes, LVNs did not follow required disinfection and hand hygiene procedures. One LVN used an alcohol prep pad instead of an EPA-approved germicide to clean the glucometer before and after use, citing a lack of appropriate supplies on the cart. Another LVN failed to perform hand hygiene after removing gloves and before handling an insulin pen, only sanitizing hands after preparing the medication. Both staff acknowledged awareness of the correct procedures and the risks associated with non-compliance. Additionally, during wound and incontinence care for a female resident with a sacral pressure ulcer, the Treatment Nurse did not perform hand hygiene after removing gloves and before re-gloving to continue wound care. This lapse occurred after cleaning a bowel movement and before re-treating the wound. The Treatment Nurse later confirmed that hand hygiene should have been performed at that point. Facility policy reviews confirmed that hand hygiene is required before and after resident contact, after glove removal, and after contact with blood or body fluids.