Infection Control Failures in Urinal Handling, Room Cleanliness, and Glucometer Disinfection
Penalty
Summary
Staff failed to follow appropriate infection prevention and control measures in several instances. In one case, a resident with multiple diagnoses, including cerebral infarction, heart failure, and chronic kidney disease, had three labeled urinals containing urine placed inside a trash can in their room. The urinals were not replaced with clean ones, and the designated urinal holder at the bedside was left empty. The resident reported that staff were inconsistent in replacing the urinal and that it was not their preference to store it in the trash can. Staff interviews confirmed that this practice did not follow standard procedures and posed an infection control risk. Facility policy required urinals to be cleaned, labeled, and stored in the designated holder, but this was not followed. Another deficiency was observed in a resident's room where multiple flying pests were present. The room contained an uncollected empty fruit cup with used tissue paper and a spoon, a mug with coffee, an empty glass, and another cup with water, all of which had attracted insects. The resident stated that staff were not cleaning the room regularly and that meal trays were not being picked up after meals. Staff confirmed that leaving food and drink at the bedside could attract insects and increase infection risk. There was no care plan documenting any refusal by the resident to have the room cleaned or trays removed, and facility policy required prompt removal of meal trays and maintenance of a pest-free environment. A further issue involved improper cleaning and disinfection of a glucometer by a licensed nurse. The nurse cleaned the device for only 10 seconds with a disinfectant towelette, not following the manufacturer's instructions, which required a two-minute wet contact time using two wipes. Both the infection preventionist and the DON confirmed that the correct procedure was not followed, increasing the risk of cross-contamination. Facility guidelines specified the need for proper cleaning and disinfection of the glucometer after each use, but this protocol was not adhered to.