Infection Control Failures in PPE Use, Hand Hygiene, and Glucometer Disinfection
Penalty
Summary
Staff failed to adhere to infection prevention and control protocols in several observed instances. A guest services aide entered two residents' rooms, both under Enhanced Droplet Precautions, without donning the required personal protective equipment (PPE) such as gown, gloves, and eye protection, as indicated by signage. The aide only wore a face mask and did not change it between rooms, although she performed hand hygiene upon exiting each room. The aide acknowledged that PPE was expected in these rooms. A certified nurse aide (CNA) was observed removing unclean gloves after providing personal care to a resident and then immediately putting on a new pair of gloves without performing hand hygiene in between. The CNA confirmed that hand hygiene should have been performed after glove removal and before donning new gloves. Additionally, an LPN was seen placing a straw into a resident's water cup with bare, unwashed hands, and admitted that she should have either washed her hands or worn gloves before handling the straw. There was also a failure to follow manufacturer and facility policy regarding the cleaning and disinfection of a shared blood glucose monitor (glucometer). An LPN used an unlabeled glucometer for multiple residents, did not have cleaning wipes readily available, and did not follow the manufacturer's instructions for cleaning and disinfecting the device between uses. The facility's policy required individual glucometers for each resident, properly labeled and stored, but this was not followed, as confirmed by the Director of Nursing.