Infection Control Failures in Equipment Cleaning, Enhanced Barrier Precautions, and Glucometer Disinfection
Penalty
Summary
The facility failed to maintain proper infection prevention and control practices in several key areas. During an observation in the utility room, two Hoyer lifts were found, with one positioned in a red-taped area labeled as 'DIRTY AREA' and a nearby cabinet labeled 'CLEAN AREA' containing unopened medical supplies. The Infection Preventionist (IP) stated uncertainty about whether the Hoyer lift was clean or dirty and acknowledged that the lift did not fit in the designated dirty area, raising concerns about potential cross-contamination. Review of records showed that seven residents used the Hoyer lift, and facility policy required cleaning and disinfecting reusable equipment between residents, in accordance with CDC guidelines. In another instance, the facility did not follow Enhanced Barrier Precautions (EBP) protocol for a resident with a stage 4 sacral pressure ulcer and a wound vac. The resident's care plan and physician order required staff to use gowns and gloves during high-contact care activities. However, a Certified Nursing Assistant (CNA) was observed providing direct care to the resident without wearing a gown, despite signage indicating the need for EBP. The CNA later confirmed awareness of the precautions but admitted to not following them during care, and the Director of Nursing (DON) confirmed that the required precautions were not followed during the incident. Additionally, the facility failed to properly clean and disinfect a shared glucometer between resident uses. During a medication pass, a Registered Nurse (RN) was observed wiping the glucometer with a single disinfecting wipe for less than ten seconds before returning it to the medication cart. Manufacturer instructions and facility policy required a two-step process using two wipes, with the device remaining wet for a specified contact time. The RN acknowledged not following the correct procedure, and both the DON and IP confirmed the expectation for staff to adhere to the two-step cleaning and disinfection process.