Infection Control Lapses in Hand Hygiene, Equipment Cleaning, and Medication Handling
Penalty
Summary
Multiple infection control deficiencies were observed throughout the facility, involving both nursing and ancillary staff. In one instance, a urinary catheter drainage bag and tubing for a resident were found on the floor, contrary to facility policy requiring these items to be kept off the floor to prevent infection. Staff confirmed the improper placement of the drainage bag. Additionally, staff were observed providing ice to residents using ice from trays stored in the employee room freezer, which was located next to employee food items. Both a CNA and activity staff confirmed this practice, while the registered dietitian stated that such ice should not be used for residents due to infection control protocols. Hand hygiene and glove use were not consistently followed. One CNA delivered a lunch tray to a resident without sanitizing hands, and another CNA left a resident's room with soiled items while still wearing gloves, only removing them after walking through the hallway. During medication administration, a nurse failed to change gloves and wash hands between giving oral medications, assisting with an inhaler, and administering eye drops. Another nurse cut a medication tablet in half, administered one half, and returned the unused half to the medication bottle, contrary to policy requiring disposal of unused portions. The same nurse also failed to clean a blood pressure cuff between residents during medication passes. During wound care, a nurse did not change gloves or cleanse hands between removing an old dressing and cleansing/applying a new dressing to a resident's heel wound. Staff interviews confirmed awareness that these actions were not in line with facility policies and infection control standards. Facility policies reviewed included specific instructions for hand hygiene, equipment cleaning, medication administration, and wound care, all of which were not followed in the observed instances.