Infection Control Deficiencies: Hand Hygiene, Equipment Disinfection, and Catheter Care
Penalty
Summary
The facility failed to ensure the use of alcohol-based hand sanitizer in hand hygiene dispensers throughout the building. During an observation, a hand sanitizer dispenser was found to contain a product labeled as benzalkonium chloride, not an alcohol-based sanitizer. Both the associate administrator and the DON were unaware that the product in use was not alcohol-based, and it was confirmed that all resident rooms had the same product. The nurse consultant verified that the product did not meet the CDC's recommendation of at least 60% alcohol content for hand sanitizers. Facility policy also required the use of alcohol-based hand sanitizer when soap and water were unavailable, but this was not followed. The facility also failed to ensure proper disinfection of shared equipment and adherence to hand hygiene and glove use protocols. A mechanical lift used for a resident on enhanced barrier precautions was not disinfected with appropriate cleaning wipes after use; instead, personal care wipes were used, which was not acceptable according to the DON. Additionally, staff did not change gloves or perform hand hygiene after providing incontinence care to two residents. In one instance, staff applied protective ointment and handled clean items with soiled gloves, and in another, a staff member wore the same gloves while assisting with multiple tasks and did not perform hand hygiene until much later. The DON stated that staff were expected to change gloves and clean their hands after such care, but this was not observed. Furthermore, the facility did not ensure that an overnight urine collection bag was cleaned prior to storage for a resident with a condom catheter. The bag and tubing were placed back into a privacy bag without being rinsed out, contrary to the expectations stated by the LPN and DON. Requested policies on equipment disinfection and care plans for some residents were not provided during the survey.