Infection Control Failures and Unreported Norovirus Outbreak
Penalty
Summary
The facility failed to ensure proper infection prevention and control practices in several key areas. During personal care for a resident with multiple comorbidities and impaired mobility, a nursing assistant was observed removing soiled incontinence products and then applying clean items without changing gloves or performing hand hygiene between tasks. The assistant exited the room to retrieve a clean gown, again without hand hygiene, and only washed hands after completing all care and removing gloves. The facility's own policy required hand hygiene after glove removal, before and after direct resident contact, and when moving from contaminated to clean body sites, but these steps were not followed. Additionally, a blood glucose monitoring device used for multiple residents was found to be in poor repair, with a crack in the plastic housing, white buildup, and a missing battery cover replaced with tape. The nurse using the device was unsure how long it had been damaged, and the unit manager questioned whether it could still be properly disinfected. The device was not immediately removed from service, despite the facility's policy and manufacturer instructions requiring equipment to be cleanable and disinfected after each use. The facility also failed to report a suspected Norovirus outbreak to the state agency as required by Minnesota law. Over a period of several weeks, 14 residents exhibited symptoms consistent with Norovirus, and isolation precautions were implemented. However, the infection preventionist did not report the outbreak, stating she was unaware of the reporting requirement. The director of nursing later confirmed that the outbreak should have been reported, in accordance with facility policy and state regulations.