Failure to Follow Infection Control Protocols and Proper Use of Insulin Pens
Penalty
Summary
Facility staff failed to adhere to infection prevention and control protocols in multiple instances. During an insulin administration, a registered nurse prepared to administer insulin to a resident using a Humalog Kwikpen labeled for a different resident. The nurse confirmed the error when questioned and subsequently obtained a new insulin vial for the correct resident. Manufacturer instructions and facility policy both specify that insulin pens are not to be used for multiple residents due to infection risk. Additionally, staff did not follow required contact and enhanced barrier precautions for residents with specific infection control needs. One resident with active C. difficile infection had physician orders and a care plan requiring contact precautions, including the use of gowns and gloves when entering the room. However, a certified nursing assistant entered the resident's room and provided care without donning a gown, and only put on gloves after entering. The same staff member then entered another resident's room without changing PPE. In another case, a resident requiring enhanced barrier precautions for wound care was assisted by a CNA who wore gloves and a mask but failed to wear a gown as required, and disposed of gloves outside the resident's room. Facility policies specify that appropriate PPE must be donned prior to entering rooms and removed before exiting.