Infection Control Lapses During Resident Care and Sharps Disposal
Penalty
Summary
The facility failed to maintain proper infection prevention and control practices during care for two residents. For one resident with dementia and frequent incontinence, a CNA performed incontinent care without following established infection control protocols. The CNA donned two pairs of gloves, changed gloves multiple times without performing hand hygiene between changes, and used the same surface area of a washcloth for multiple wipes without refolding or changing to a clean area. The CNA acknowledged being aware of the correct procedures but did not follow them during the observed care. Interviews with facility staff, including the infection control nurse and the DON, confirmed that double gloving is not recommended, and hand hygiene is required between glove changes. The facility's policy also specifies that a new section of a washcloth or a new disposable wipe should be used for each wipe during perineal care. The observed actions did not align with these policies, and staff recognized the risk of contamination and infection resulting from these lapses. In a separate incident, an LVN checked a diabetic resident's blood glucose using a lancet and then improperly disposed of the used lancet in the resident's room trash can instead of a designated sharps container. The LVN admitted this was not the correct procedure and acknowledged the potential infection control concern. The DON also confirmed that used lancets should be disposed of in sharps containers, as improper disposal poses a significant infection control risk.