Infection Control Deficiencies During Blood Glucose Monitoring and Meal Service
Penalty
Summary
The facility failed to maintain proper infection control practices during fingerstick blood glucose monitoring for one resident, with the potential to affect three additional residents receiving similar care. During observation, an LPN placed a glucometer directly on a resident's overbed table without a barrier, used gloves to obtain a blood sample, and then placed the glucometer on a tissue. The LPN changed gloves multiple times without performing hand hygiene between glove changes, and cleaned the glucometer for only five seconds, despite manufacturer guidelines requiring a two-minute contact time for disinfection. The LPN also prepared medication after glove removal, using hand sanitizer only after several glove changes without prior hand hygiene. These actions were confirmed during an interview with the LPN, and a review of facility policy indicated that hand hygiene should be performed after glove removal. Additionally, the facility failed to ensure hand hygiene was performed during meal service for three residents in the main dining room. A CNA was observed serving and assisting with meal trays for these residents without performing hand hygiene before or during the process. The CNA confirmed during an interview that hand hygiene was not completed as required. Facility policy identifies hand hygiene as the primary means to prevent the spread of healthcare-associated infections. The affected residents had various medical conditions, including high blood pressure, dysphagia, dementia, respiratory failure, epilepsy, anxiety, depression, and heart failure.