Infection Control Failures in Glucometer Disinfection, Hand Hygiene, and Oxygen Equipment Maintenance
Penalty
Summary
Staff failed to follow infection prevention and control protocols related to the use of blood glucose monitoring machines and hand hygiene. Observations revealed that an LPN did not sanitize the blood glucose monitoring machine before or after obtaining blood sugar readings for multiple residents. The same LPN also failed to perform hand hygiene after removing gloves and before leaving a resident's room, as well as before and after administering medications. These actions were in direct violation of the facility's policies, which require cleaning and disinfecting glucometers between each use and performing hand hygiene at appropriate times. Additionally, a medication aide was observed not following the manufacturer's instructions for disinfecting the glucometer. The aide used a Sani cloth germicidal wipe for only 8 seconds, despite the manufacturer's recommendation of a two-minute wet contact time. The aide was unaware of the required contact time, resulting in improper disinfection of the device between resident uses. There were also deficiencies in the management of oxygen equipment for a resident with chronic respiratory failure, hypoxemia, obstructive sleep apnea, and Williams syndrome. The resident's oxygen concentrator filter was observed to have a thick gray fuzzy coating, indicating it had not been cleaned as required. The nasal cannula was found on the floor and was not replaced or cleaned before being placed back on the resident. Staff walked by without addressing the resident's oxygen needs, and the resident was later found with low oxygen saturation. The filter was only cleaned after being pointed out, and the nasal cannula that had been on the floor was used without cleaning.