Failure to Follow Infection Control Practices for Insulin Administration, Catheter Care, and Hand Hygiene
Penalty
Summary
The deficiency involves multiple failures in the facility’s infection prevention and control practices, including improper use of multi-dose insulin pens, inadequate hand hygiene, and incorrect use of personal protective equipment (PPE) and supplies during resident care. For one resident with diabetes mellitus, anxiety disorder, and heart failure, who was cognitively intact and received insulin, the clinical record showed that an LPN administered various types of insulin on multiple dates. Facility policy stated that multi-dose insulin pens were for single-resident use only and that changing the needle did not make it safe to use insulin pens for more than one resident. Despite this, the LPN later reported that she borrowed insulin pens from other residents who used the same type of insulin and did not know which residents the pens originally belonged to. Another cognitively intact resident with diabetes mellitus, muscle weakness, and a cognitive communication deficit also received insulin injections. The resident’s care plan did not address insulin use. The medication administration record documented that the same LPN administered long-acting and fast-acting insulin to this resident on several dates. A corrective action form and staff interviews described that this LPN did not dispose of insulin pens from discharged residents and reused those pens, as well as other current residents’ pens, for multiple residents using the same type of insulin. One LPN reported finding a bag of insulin pens with multiple resident names and a pen with a used, blood-contaminated needle attached, and stated she was instructed by the LPN to use these pens until they were gone. The deficiency also includes failures in basic infection control practices during catheter care and personal care for residents on Enhanced Barrier Precautions (EBP). One resident with benign prostatic hyperplasia, diabetes, a history of stroke, and an indwelling urinary catheter required catheter care every shift and was on EBP. During observed care, a CNA donned a gown and gloves without performing hand hygiene, placed a urine graduate directly on the bathroom floor without a barrier, drained the catheter bag into the graduate, and then used the same contaminated gloves to handle her gown, reach into her uniform pocket for an alcohol swab, cleanse the catheter port, open the bathroom door, and empty the graduate into the toilet. The CNA then placed the graduate on a paper towel by the toilet, removed PPE, and proceeded to other resident care tasks without documented hand hygiene between activities. Facility policies required hand hygiene before, during, and after care, glove changes between dirty and clean tasks, single-use gloves, and proper handling and placement of the graduate, but these steps were not followed. Additional observations of personal care for another resident showed staff not performing hand hygiene or changing gloves between dirty and clean tasks. During incontinence care and dressing, staff used gloved hands to remove a soiled brief, clean the genital area after a bowel movement, reposition the resident, adjust bedding, and then change the resident’s clothing and handle the resident’s head/face area, all without changing gloves or performing hand hygiene until after the care was completed. Facility policies on hand hygiene and glove use required hand hygiene at the start and end of care, and whenever moving from a contaminated task to a clean task, as well as single-use gloves to be discarded after each use. These observed practices did not comply with the facility’s infection prevention and control program, catheter care policy, PPE policy, or hand hygiene policy.
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