Failure to Implement Infection Control Practices During Resident Care and Glucometer Use
Penalty
Summary
Facility staff failed to implement infection control policies and procedures during high-contact care activities and the use of shared medical equipment. Nurse #12 did not don personal protective equipment (PPE) as required for enhanced barrier precautions (EBP) when providing care to a resident with a gastrostomy tube, indwelling urinary catheter, and tracheostomy tube. During medication administration and tracheostomy care, Nurse #12 did not wear a gown, gloves, or mask, and also failed to perform hand hygiene between different care activities for the same resident. Interviews with the Infection Preventionist, Director of Nursing, and Administrator confirmed that PPE should have been used for such high-contact interactions and that hand hygiene was required before moving from one body part to another. Additionally, staff did not follow the manufacturer's instructions for cleaning and disinfecting a shared blood glucose meter between resident uses. Observations showed that Nurse #14 and Nurse #15, when performing blood glucose checks for two different residents, used only one EPA-approved germicidal wipe to clean the glucometer after use, instead of using two wipes as specified in both the facility policy and the manufacturer's instructions. The first wipe was intended for cleaning, and the second for disinfection, with the device to be left visibly wet for at least two minutes. Both nurses failed to use the second wipe, and one nurse did not clean the glucometer before use. At the time of the investigation, there were three residents in the facility with bloodborne pathogens, increasing the importance of proper disinfection practices. The Infection Preventionist, DON, and Administrator all confirmed that shared glucometers should be disinfected according to policy and manufacturer guidelines to prevent the spread of bloodborne infections. The deficient practices were identified for three of six staff members observed for infection control compliance.