Failure to Follow Infection Control Protocols for EBP and Equipment Cleaning
Penalty
Summary
The facility failed to adhere to CDC guidelines and its own policies regarding infection prevention and control, specifically in the application of Enhanced Barrier Precautions (EBP) and the handling of medical equipment. In one instance, a resident with a history of cerebral infarction, hemiplegia, diabetes, and pleural effusion received nebulizer therapy from an LPN who, after administering the treatment, placed the used nebulizer mask back into a plastic bag without cleaning or disinfecting it as required by facility policy. The LPN did not follow the procedure of rinsing, drying, and storing the equipment properly after use, and did not clean the equipment even after being observed for an extended period post-treatment. Another deficiency involved a resident with partial arterial traumatic amputation, diabetes, peripheral vascular disease, immunodeficiency, and a local skin infection, who was under EBP. During a blood glucose monitoring procedure, an LPN failed to perform hand hygiene before entering the resident's room, placed uncleaned supplies on the resident's meal table without disinfecting it, and did not allow the alcohol to dry before pricking the resident's finger. The LPN also brought a whole container of glucose strips into the room, used it during the procedure, and then returned it to the medication cart without disinfecting it, contrary to both CDC guidelines and facility policy. The LPN also failed to disinfect the resident's table after the procedure and did not discard supplies that should not be reused. Additionally, the Assistant Director of Nursing (ADON) entered the EBP resident's room without performing hand hygiene, despite clear signage indicating EBP protocols. The ADON admitted to not following hand hygiene protocols, even though he was aware of the EBP status. The Infection Preventionist confirmed that reusable supplies should not be brought into EBP rooms and that any such items must be discarded if they enter the room. The Director of Nursing (DON) was informed of the improper handling of the glucose strip container but did not take immediate corrective action. These actions and inactions demonstrate a failure to implement and follow infection prevention and control protocols as required.