Failure to Follow Infection Control Protocols During Resident Care and Medication Administration
Penalty
Summary
Staff failed to comply with infection prevention and control guidelines in several instances involving residents on transmission-based precautions, during perineal care, and while administering medications. For one resident with a right lower leg fracture and ankle wound, who was on Enhanced Barrier Precautions (EBP), a nursing assistant entered and exited the resident's room without donning any personal protective equipment (PPE) despite a posted EBP sign and available PPE cart. The nursing assistant later confirmed assisting the resident with toileting without PPE, and another staff member was unclear about the PPE requirements for this resident. During perineal care for another resident, a nursing assistant did not perform hand hygiene after removing gloves and before donning new ones, instead placing contaminated hands into the glove box and continuing care. The staff member acknowledged the lapse, and the facility's infection preventionist confirmed that hand hygiene should be performed each time gloves are removed during perineal care. In medication administration, a nurse used a glucometer in a resident's room and then placed the contaminated device and supplies on the medication cart without a barrier, disinfected the glucometer but not the cart, and repeated similar actions with an insulin pen. The nurse admitted that used equipment should be considered contaminated until disinfected and that barriers should have been used under the equipment both in the resident's room and on the medication cart. The infection preventionist confirmed that these steps were required by facility policy.