Failure to Perform Hand Hygiene and Sanitize Shared Equipment
Penalty
Summary
The facility failed to adhere to infection prevention and control protocols, specifically regarding hand hygiene and equipment sanitation. A licensed nurse did not perform hand hygiene before preparing a glucometer for a blood glucose check, nor before entering a resident's room or administering IV medication. The nurse also used the same alcohol wipe to clean the glucometer, the resident's finger, and the insulin pen hub, contrary to established procedures. Additionally, a certified nurse's aide did not sanitize a Hoyer lift after use with one resident before making it available for use with others. Staff interviews confirmed awareness of the required hand hygiene and equipment sanitation protocols, but also revealed inconsistent practices, particularly with the Hoyer lift, which was not always sanitized between residents. The facility's own policy, aligned with CDC guidelines, mandates hand hygiene before and after resident contact and after contact with medical equipment, as well as sanitizing shared equipment between uses. These lapses in protocol were observed directly by surveyors and acknowledged by staff during interviews.