Failure to Follow Hand Hygiene, PPE, and Glucometer/Vital Sign Equipment Cleaning Protocols
Penalty
Summary
The deficiency involves the facility’s failure to follow standard infection prevention and control practices, including hand hygiene, PPE use, and cleaning of resident care equipment such as vital sign (VS) equipment and a glucometer. Facility handouts from the Infection Prevention Manual for Long Term Care, revised 02/2018, directed staff to perform hand hygiene as part of donning PPE and to remove PPE at the doorway before leaving a resident’s room, followed immediately by hand hygiene. Despite these written procedures, staff actions during medication administration and resident care did not align with these guidelines. During continuous observation, one LPN prepared medications for a resident without performing hand hygiene, placing multiple pills into small plastic medication cups and handling the cups in the palm of unclean hands before entering the resident’s room. After the resident ingested the medications, the LPN discarded the cups, exited the room, returned to the medication cart, documented medication administration, and proceeded to another resident’s room without performing hand hygiene. Later, the same LPN was observed to perform hand hygiene before entering another resident’s room, but then inconsistently applied hand hygiene practices before and after subsequent resident care tasks. For a resident on precautions requiring gown and gloves for high-contact care, the LPN performed a blood glucose check, exited the room wearing PPE, walked down the hall, discarded an item in the sharps container, placed the glucometer on top of the medication cart, removed gown and gloves in the hallway, and returned to the cart without performing hand hygiene. The LPN then re-gowned and re-gloved without hand hygiene, entered the resident’s room with the VS cart, and later exited with PPE still on, parked the VS cart by the medication cart, removed PPE at a hallway trash can, and began preparing the resident’s medications without hand hygiene or sanitizing the VS cart or its components. The glucometer, which manufacturer guidelines required to be cleaned with soap and water or 70–80% isopropyl alcohol after use, was placed on the medication cart, then returned to its storage bag and cart drawer without being cleaned. The LPN acknowledged they were supposed to clean the glucometer with an alcohol pad after use but did not do so. Additionally, the administrator noted the lack of trash cans inside rooms of residents on precautions and stated this was unusual.
We Help Long-Term Care Teams Stay Survey-Ready
We process and analyze inspection reports and plan of correction using AI to extract insights and trends so providers can improve care quality and stay ahead of compliance risks.