Failure to Disinfect Resident Care Devices and Follow Infection Control Practices
Penalty
Summary
Facility staff failed to properly disinfect resident care devices and adhere to infection control practices as observed during routine care of two residents. In one instance, a resident with a history of pneumonia, on antibiotics, and receiving tube feeding via a gastrostomy tube was attended by an LPN who donned appropriate personal protective equipment but placed a used stethoscope on the resident's blanket and later draped it over her neck without disinfecting it. The LPN also handled trash and opened the resident's door with gloved hands, then continued care activities without changing gloves as required. The care plan for this resident indicated the need for enhanced barrier precautions due to the risk of multidrug-resistant organisms (MDRO) related to the indwelling tube. In another instance, an RN checked a resident's blood sugar and cleaned the glucometer with an alcohol swab for less than five seconds before storing it, despite the device being used on multiple residents. Facility policy and manufacturer instructions required the use of a specific disinfectant wipe with a two-minute wet contact time for proper disinfection. Interviews with the Director of Nursing confirmed expectations for staff to follow these infection control protocols, which were not met in these observed cases.