Infection Control Failures in Hand Hygiene, PPE Use, and Equipment Disinfection
Penalty
Summary
Multiple deficiencies in infection prevention and control practices were observed among staff during medication administration, resident care, and use of medical equipment. A registered nurse failed to perform hand hygiene after exiting a resident's room and before preparing and administering insulin injections to another resident. The nurse also did not wash hands before donning gloves, exited the room with the same gloves, and handled medication equipment without performing hand hygiene. These actions were confirmed by the nurse during the interview. Certified nursing assistants did not follow Enhanced Barrier Precautions (EBP) when providing care to residents with indwelling catheters. Specifically, staff did not don isolation gowns or perform hand hygiene before or after providing catheter care, despite signage indicating EBP requirements. One CNA provided catheter care to a resident with an indwelling catheter and then entered another resident's room without washing or sanitizing hands. Another CNA and an LPN also failed to don gowns or perform hand hygiene as required during high-contact care activities for residents on EBP. A medication technician used a single glucometer for blood sugar assessments on two residents without cleaning or disinfecting the device between uses, contrary to CDC guidance and manufacturer instructions. The technician also failed to remove gloves or perform hand hygiene between residents. The Director of Nursing confirmed that staff were expected to clean glucometers between each use and to perform hand hygiene before and after resident care. Facility policies and CDC guidance reviewed during the investigation supported these requirements, but staff interviews and observations revealed consistent non-compliance.