Failure to Perform Hand Hygiene During Blood Glucose Monitoring
Penalty
Summary
The facility failed to ensure that staff consistently performed hand hygiene before and after wearing gloves during blood glucose checks for five residents. Observations revealed that an LPN performed hand hygiene at the medication cart but did not consistently perform hand hygiene before donning gloves or after removing them when conducting blood glucose monitoring. The LPN was seen entering resident rooms, including those under enhanced precautions, donning gloves and gowns without prior hand hygiene, and performing fingerstick glucose checks. In several instances, the LPN removed gloves and gowns outside the resident rooms and failed to perform hand hygiene before proceeding to the next task or resident. The LPN was also observed handling the glucometer, medication cart, computer, and other supplies without performing hand hygiene between glove changes or after glove removal. Supplies such as lancets and testing strips were retrieved and handled without appropriate hand hygiene, and the LPN was seen touching personal items, such as cart keys and pockets, in between resident care activities. In some cases, the LPN cleaned the glucometer while wearing gloves, removed the gloves, and then failed to perform hand hygiene before touching other surfaces or equipment. Interviews with the LPN confirmed the failure to perform hand hygiene as required. The facility's infection prevention policy specifies that hand hygiene must be performed before donning gloves and after removing them, especially when performing procedures involving potential exposure to blood or body fluids. The Infection Preventionist stated that it was her expectation for staff to follow these protocols, but the observed practices did not align with facility policy.