Failure to Follow Infection Control Practices During Wound Care and Glucometer Disinfection
Penalty
Summary
Nurse #1 failed to follow the facility's infection control policy by not performing hand hygiene before donning gloves prior to assisting with wound care for a resident with an open, draining boil. During the observation, Nurse #1 walked past a hand sanitizer dispenser without using it, donned a gown and gloves inside the resident's room, and assisted with the dressing change without first cleaning her hands. After completing the wound care and removing her gloves and gown, Nurse #1 used hand sanitizer only after leaving the resident's room. Both the Nurse Supervisor and the facility's Director of Nursing confirmed that hand hygiene should have been performed before donning gloves and after removing them, as outlined in the facility's policy and infection control standards. In a separate incident, Nurse #3 did not properly clean and disinfect an individually assigned glucometer after performing a blood glucose check for a resident. The glucometer was stored in a labeled plastic bag outside the resident's room. After use, Nurse #3 used only one EPA-approved disinfectant wipe for 8 to 10 seconds, rather than the manufacturer's recommended two wipes and required wet contact time of two minutes. The glucometer was then returned to the plastic bag and stored in the medication cart drawer. Nurse #3 later acknowledged not following the correct disinfection procedure, despite having received prior training on the process. Interviews with the Administrator, Director of Nursing, and Medical Director confirmed that the observed practices by Nurse #1 and Nurse #3 did not align with the facility's infection prevention and control policies or the manufacturer's instructions for equipment disinfection. These lapses were identified during observations and staff interviews, and were confirmed through review of facility policies and manufacturer guidelines.