Multiple Lapses in Infection Control Practices
Penalty
Summary
The facility failed to maintain an effective Infection Prevention and Control Program, as evidenced by multiple observed lapses in infection control practices involving four residents. One incident involved a nurse administering intravenous antibiotics to a resident with a venous access device who was on Enhanced Barrier Precautions (EBP). The nurse performed hand hygiene and donned gloves but failed to wear a gown as required by EBP protocols, despite signage indicating the need for such precautions. The nurse later acknowledged confusion about the required personal protective equipment (PPE) for different situations, even though he had received training. Additional deficiencies were observed in the disinfection of glucometers used for fingerstick blood sugar testing on two residents. Nurses wiped the glucometers with germicidal wipes but did not allow the devices to air dry for the required contact time before returning them to the medication cart, potentially leading to cross-contamination. One nurse was unaware of the need to let the device air dry, and the facility did not have a specific policy for glucometer disinfection, relying instead on manufacturer instructions. Further lapses included a medication aide carrying eye drops and nasal spray into a resident's room, placing them on the bed and resident's chair, and failing to perform hand hygiene before administering the medications. The aide also failed to discard the medications after they were dropped on the floor, instead returning them to the medication cart. In another instance, a CNA did not perform hand hygiene after transferring a resident to a wheelchair and before leaving the room, contrary to facility policy. These actions were confirmed through staff interviews and record reviews, demonstrating a pattern of non-compliance with established infection control protocols.