Multiple Lapses in Infection Control Practices by Nursing Staff
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by multiple observed lapses in infection control practices by staff and lack of adherence to established protocols. Specifically, a registered nurse (RN) did not sanitize a blood glucose monitor between uses for two residents, despite using the same device consecutively. The RN acknowledged during an interview that the monitor should be sanitized between residents to prevent the spread of pathogens. Additionally, the RN handled a medication pill with bare hands after touching various surfaces, including keys and a computer keyboard, before administering the medication to a resident. The RN stated he believed it was acceptable to touch pills with bare hands but later recognized the potential for contamination. Further deficiencies were observed in the administration of insulin, where the RN failed to clean the rubber stopper of an insulin pen with an alcohol swab prior to attaching the needle and administering the medication. The Director of Nursing (DON) indicated that while the facility's policy did not specify cleaning the pen, it would be important to prevent cross-contamination. Manufacturer guidelines for the insulin pen recommend wiping the pen tip with an alcohol swab before use, which was not followed in this instance. Additional infection control lapses included a licensed vocational nurse (LVN) not using a clean paper towel to turn off the faucet after handwashing, instead using bare hands, which could lead to recontamination. The LVN stated that paper towels were not easily accessible and acknowledged the correct procedure. The facility also failed to implement Enhanced Barrier Precautions (EBP) for a resident with a surgical wound and a wound vacuum device, as required by facility policy. The resident's room lacked appropriate EBP signage, and the DON confirmed that EBP should have been in place for this resident due to the risk of infection associated with her wound.