Failure to Follow Infection Control Protocols During Resident Care
Penalty
Summary
The facility failed to maintain proper infection prevention and control practices for one resident who was observed coughing up copious amounts of thick phlegm. During the incident, a nurse (LVN-A) handled a paper towel containing the resident's phlegm without wearing gloves and disposed of it by walking out to the medication cart in the hallway. The nurse then returned to the resident's room, provided a cup for the resident to spit into, and only washed her hands after these actions. The nurse stated she did not wear gloves because she believed it was a dignity issue for the resident and did not consider it an infection control issue at the time. The resident involved had a history of cerebral infarction, expressive language disorder, and seizures, and was noted to be lethargic with slurred speech and coughing up phlegm on the day of the incident. The facility's infection prevention and control policy requires staff to use standard precautions, including the use of gloves and proper hand hygiene when handling potentially infectious materials. Both the ADON (infection control nurse) and DON confirmed that gloves should have been worn and hand hygiene performed according to policy, and that the nurse's actions did not follow established infection control procedures.