Infection Control Deficiencies: Hand Hygiene and Equipment Cleaning Lapses
Penalty
Summary
The facility failed to implement proper infection prevention and control measures in several instances involving both staff and equipment. During observations, the filters of two residents' oxygen concentrators were found to be dusty, despite facility policy and manufacturer recommendations requiring weekly cleaning and preventive maintenance. The infection preventionist confirmed that the filters should have been cleaned, but this was not done as required. Multiple staff members did not adhere to hand hygiene protocols. One certified nursing assistant (CNA) was observed leaving a resident's room with gloves on, disposing of trash in the hallway, and then returning to the resident's room to continue care without changing gloves or sanitizing hands. The same CNA also failed to sanitize hands after removing gloves before retrieving supplies. Another CNA removed gloves after repositioning a resident but did not sanitize hands before assisting with the resident's meal or before leaving the room, handling food items and utensils with potentially contaminated hands. A licensed vocational nurse (LVN) was observed administering oral medications to two residents consecutively without performing hand hygiene before or after glove use, or between resident contacts. The LVN acknowledged the lapse in hand hygiene, and the Director of Nursing confirmed that hand hygiene is required between residents during medication administration. Facility policies reviewed support the need for hand hygiene before and after glove use, between resident contacts, and before handling medications.