Failure to Follow Hand Hygiene and Linen Transport Protocols
Penalty
Summary
Staff failed to follow proper hand hygiene protocols during blood glucose testing for a resident diagnosed with type 2 diabetes mellitus with diabetic peripheral angiopathy. Specifically, an LPN changed gloves without performing hand hygiene between glove changes while conducting a finger stick blood glucose test. The LPN later acknowledged that hand hygiene should have been performed between glove changes but stated she was overwhelmed at the time. Additionally, infection control procedures were not followed during the transportation and handling of clean linen and resident clothing. A laundry attendant was observed transporting clean linen in a covered cart, but resident clothing was hanging uncovered from the cart's handlebars, coming into contact with hallway walls and handrails. Clean clothing was also observed with part of a garment resting on the floor in the laundry room. The laundry attendant confirmed a lack of awareness regarding the need to keep resident clothing covered and admitted to having transported uncovered laundry multiple times.