Infection Control Deficiencies in Hand Hygiene, Glucometer Cleaning, and Laundry Handling
Penalty
Summary
Surveyors observed that a registered nurse failed to consistently perform hand hygiene during blood glucose monitoring and insulin administration for a resident on the memory care unit. The nurse applied gloves before retrieving the glucometer, performed the blood glucose test, and then returned the glucometer to the medication cart without cleaning or disinfecting it. The nurse also failed to perform hand hygiene after removing gloves and before donning new gloves for insulin administration, as well as after completing the insulin injection. The nurse acknowledged that hand hygiene should have been performed at multiple points and that the glucometer should have been disinfected after each use, but stated that cleaning was sometimes delayed due to competing responsibilities. Additionally, the facility did not ensure proper handling and containment of soiled personal laundry and linens. In the main laundry washroom, soiled clothing was transported unbagged across areas where clean clothing was stored, and clean clothing and bedding were placed in garbage bags or boxes directly on the floor. In the upstairs laundry unit, soiled laundry was placed on the floor before sorting, and clean clothing was placed on countertops near sinks, which were identified as highly contaminated areas. Mechanical lift slings were also stored in baskets and boxes on the floor. The housekeeper responsible for laundry acknowledged that soiled items were not always bagged prior to transport and that clean items should not be stored on the floor. Facility policies required that glucometers be disinfected after every use and that hand hygiene be performed before and after resident care, after glove removal, and after contact with potentially contaminated items. Policies also specified that soiled laundry should be bagged at the point of use and that clean linens should be handled and stored to prevent contamination. However, these procedures were not consistently followed, as confirmed by staff interviews and direct observation.