Failure to Follow Hand Hygiene and Medication Handling Practices
Penalty
Summary
Surveyors identified a deficiency in the facility’s implementation of its infection prevention and control program and hand hygiene policies. The facility’s Handwashing/Hand Hygiene policy states that all personnel must follow hand hygiene procedures to prevent the spread of infections, including using alcohol-based hand rub or soap and water before and after direct resident contact and after removing gloves, and clarifies that glove use does not replace hand hygiene. The Infection Prevention and Control Program policy states the facility maintains a program to prevent the development and transmission of communicable diseases and infections according to accepted standards. For one resident with diabetes mellitus type 2, admitted with diagnoses including diabetes and assessed as having severe cognitive impairment, the physician’s orders directed administration of metformin 500 mg tablets, two tablets by mouth twice daily. During a medication pass, an LPN used her bare hands to place a metformin tablet into a pill cutter to split a 1000 mg tablet into two halves for administration, rather than using gloves or another barrier. The LPN later confirmed she had handled the tablet with bare hands and acknowledged that this could cause cross contamination. The DON stated her expectation that nurses do not handle medications with bare hands because bare hands could contaminate pills and residents could receive whatever contamination was on the pills, possibly infection. For another resident admitted with diagnoses including dysphagia, rarely or never understood, and receiving nutrition via a feeding tube, the care plan documented the need for bolus PEG tube feeding and monitoring for signs and symptoms of aspiration and infection at the tube site. Physician’s orders directed cleansing of the G-tube site with sterile saline, drying, applying skin protectant, and covering with split gauze secured with tape. During G-tube care, an LPN changed gloves but did not sanitize or wash her hands between glove changes. The LPN confirmed she did not perform hand hygiene between glove changes, explaining that the hand sanitizer station in the room was empty and acknowledging she should have washed her hands. The nurse manager and DON both confirmed that facility expectations are that staff wash or sanitize hands any time gloves are removed and between glove changes, and that failure to do so is an infection control issue that could lead to healthcare-associated infections.
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