An LPN was observed cleaning a community-use glucometer with an alcohol pad instead of the bleach wipe or equivalent required by the facility policy. The LPN stated he always used alcohol pads, while the DNS stated staff were to use bleach wipes. The glucometer was used for CBG checks on several residents with diabetes, and their records did not indicate a BBP.
Improper disinfection of a shared glucometer was observed when an LPN returned from checking a resident’s CBG and placed the device in a drawer without disinfecting it. The facility policy and glucometer manual required EPA-approved disinfectant wipes, but the LPN stated she used alcohol pad wipes instead because she felt the EPA wipes were harsh. The DNS confirmed staff were to use approved EPA disinfectant wipes.
Infection control failures occurred during catheter care, medication administration, and wound care. Two residents had catheter bag drains that touched the floor, and one CNA initially handled a urine-filled bag without PPE. An RN failed to sanitize hands, used improper glove practices, and discarded a lancet and blood test strips in regular trash during CBG testing. Another RN administered meds without proper hand hygiene or PPE, picked pills up from a resident’s shirt and bed with bare hands, and touched the call light with dirty gloves. During wound care, staff placed clean supplies on a dirty bedside table and bed, handled dirty items and a cell phone, and missed required hand hygiene and glove changes.
Failure to Use PPE for Resident on Contact Precautions: A resident on contact precautions had a door sign and PPE bin outside the room, but the sign did not show what to don before entry or where to doff PPE. A housekeeper was observed entering the room, cleaning the bathroom, and handling trash without a gown or mask, and later stated she did not know what the sign meant or what to do. The LPN, EVS Manager, Administrator, and DNS acknowledged the PPE was not worn before entering the room.
A CMA failed to follow infection control technique while preparing medication for administration through a resident’s feeding tube. The medication cup, fluids used to mix the medication, and syringe were placed on the bedside table without a clean barrier, and the Administrator and DNS acknowledged the lapse.
A shared glucometer was not properly disinfected between resident CBG checks. A nurse wiped the device with an alcohol pad instead of an EPA-approved disinfectant wipe, despite the facility policy and manufacturer instructions requiring approved disinfectant use after each resident. The resident involved had Hepatitis B and received routine CBG monitoring, and multiple staff members used the same glucometer.
A nurse failed to disinfect a shared glucometer between resident CBG checks, using the same unsanitized meter for two residents instead of cleaning it after each use. The nurse also performed wound care for a resident on EBP while wearing gloves and a mask but no gown, despite an EBP sign on the door and facility expectations for gown and glove use during high-contact care.
Failure to Develop and Implement Water Management Plan for Legionella Control: The facility did not develop or implement an effective water management plan to identify areas where water-borne pathogens could grow and spread. Records showed no documented water system risk assessment in the facility assessment or Legionella control plan, and the plan contained another facility's name. The Administrator and Maintenance Director stated they used a template from another facility, and the Administrator said staff believed there was nowhere pathogens could grow because water was always in use, but no documentation of that assessment was provided.
Staff failed to follow infection control practices involving catheter positioning, hand hygiene, and EBP. A resident’s catheter was repeatedly observed resting on the floor, a CNA provided high-contact care to a resident with an indwelling catheter without donning a gown, an LPN handled medication-cart items without hand hygiene after dropping an item on the floor, and a resident with a PICC line received IV/PICC care without the expected PPE.
Failure to perform hand hygiene during wound care was observed for a resident with diabetes and a pressure ulcer. An LPN removed the old dressing and adjusted the resident’s incontinent brief, then acknowledged gloves should have been changed when moving from a dirty task to a clean task and that hand hygiene should have been performed before putting on clean gloves. The DNS stated staff were expected to follow infection control standards, including changing gloves as needed and performing hand hygiene when gloves were removed.
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