Failure to Maintain Infection Prevention and Control Practices
Penalty
Summary
The facility failed to maintain an effective Infection Prevention and Control Program, as evidenced by multiple instances of staff not performing required hand hygiene during resident care. In one case, a male resident with type 2 diabetes had his blood sugar checked by an LVN who did not perform hand hygiene before or after the procedure, nor after cleaning the glucometer. The LVN changed gloves multiple times without sanitizing her hands and handled the glucometer and medication cart without proper infection control practices. Another incident involved a male resident with type 2 diabetes whose blood sugar was checked by the same LVN in the dining room. The LVN did not perform hand hygiene before or after the procedure, placed the soiled glucometer on the dining room table, and changed gloves without sanitizing her hands. The LVN acknowledged she was aware of the required protocols but did not have hand sanitizer on her cart and admitted to the risk of cross-contamination by her actions. The resident stated he would have complied with being moved for the procedure if asked. A third incident involved a female resident with Alzheimer's who received peri-care from a CNA who did not perform hand hygiene before or after care, and handled clean briefs with soiled gloves. The CNA also left the resident's room without sanitizing her hands. The CNA stated she believed wearing gloves kept her hands clean and was unaware of the need to change gloves and perform hand hygiene between glove changes. The facility's policy required hand hygiene before and after care, after glove removal, and after contact with potentially contaminated surfaces.