Failure to Follow Hand Hygiene and Device Change Orders for Infection Control
Penalty
Summary
The facility failed to maintain an infection prevention and control program when nursing staff did not follow CDC hand hygiene practices and did not use appropriate barriers during medication administration. One LPN prepared an insulin pen and transdermal patches at the medication cart, then entered a resident's room without performing hand hygiene or donning gloves. She placed the insulin pen directly on a bedside table next to a bedside urinal without a barrier, applied a transdermal pain patch with an ungloved hand, then donned gloves without prior hand hygiene to administer an insulin injection. After removing gloves and performing hand hygiene, she applied a transdermal nicotine patch with an ungloved hand. When questioned, the LPN stated she was not aware a barrier was needed between the insulin pen and the bedside table and did not respond when asked about hand hygiene upon room entry and prior to donning gloves. In a separate observation, an RN prepared oral medications at the medication cart, then entered a resident's room and handed the medications and water to the resident without performing hand hygiene or donning gloves. The DON stated her expectation was that nurses perform hand hygiene upon entering a resident's room and don gloves prior to administering insulin or transdermal patches. The facility also failed to follow a physician's order related to infection control for a resident with a gastrostomy tube. This resident had multiple diagnoses including diabetes, protein calorie malnutrition, and dysphagia, and had undergone a procedure for gastrostomy tube placement. A physician's order directed staff to change and date the resident's syringe and graduated cylinder every night shift. During observation, the resident's graduated cylinder and syringe were found on top of the dresser, with the graduated cylinder dated several days earlier and the syringe undated. The ADON confirmed that the graduated cylinder and syringe should be changed every night and dated, and the DON stated that the nightly change was ordered for infection control purposes.
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