Failure to Clean Blood Spill After IV Therapy
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the presence of blood splatters on the floor of a resident's room following IV therapy. The resident, an elderly female with multiple medical diagnoses including metabolic encephalopathy, hypertension, atrial fibrillation, hypothyroidism, and vitamin deficiency, had received IV medications and fluids. Despite orders for monitoring signs of infection and maintaining a clean environment, several areas of dried blood were observed on the floor near the resident's bed the day after the IV was administered. Interviews revealed that the resident was aware of the blood on the floor and expressed concern about tracking it around the room with her wheelchair. A family member also noticed the blood and voiced concerns about cleanliness and the potential for spreading contaminants. The Housekeeping Supervisor stated she was not notified of the blood spill and confirmed that rooms are cleaned daily, but emphasized that blood spills should be cleaned immediately and reported to housekeeping for proper disinfection. The Director of Nursing and the Administrator both stated that their expectation is for blood spills to be cleaned up right away by staff and reported to the appropriate personnel. A review of the facility's policy on cleaning blood and body fluid spills indicated that all such spills should be cleaned and disinfected as soon as practical, with staff required to use appropriate personal protective equipment and approved disinfectants. The policy also states that all exposures should be reported to the infection control coordinator. In this instance, the failure to promptly clean and disinfect the blood spill and notify housekeeping was a direct violation of facility policy and infection control standards.