Failure to Follow Hand Hygiene and Equipment Cleaning Protocols
Penalty
Summary
A Licensed Practical Nurse (LPN) failed to follow standard infection control practices during the care of two residents, one of whom was under contact precautions for candida auris and the other for a urinary infection. The LPN entered a resident's room with contact precaution signage, used a blood pressure cuff on the resident, touched the bed's footboard, and then exited the room without performing hand hygiene or cleaning the blood pressure cuff. The blood pressure cuff was placed on the medication cart and later moved to another location without being disinfected. The LPN continued to interact with other staff, access the wound care cart, and begin medication administration for another resident, all without performing hand hygiene between tasks or after glove removal. Facility policy requires hand hygiene before and after direct resident contact, after glove removal, and after contact with resident care equipment. The LPN repeatedly failed to perform hand hygiene at required intervals, including before and after entering isolation rooms, after removing gloves, and after using shared equipment. Additionally, the blood pressure cuff, a non-critical reusable item, was not cleaned or disinfected between residents as required by facility policy and CDC guidelines. These actions were confirmed through observation, interview with the Director of Nursing, and review of facility policies.