Finding Description
Based on observation, interview, record review, and the review of a facility document titled, Hand Hygiene Policy, the facility failed to ensure Employee Identifier (EI) #1, a Licensed Practical Nurse (LPN), removed her gloves and washed her hands, perform hand hygiene, before leaving a resident's room after giving an injection.
This affected 1 of six residents observed during medication pass, conducted by 1 of three nurses, on 1/30/19.
Finding include:
The facility document titled, Hand Hygiene Policy copyright date 2018, included: . Staff involved in direct resident contact will perform proper hand hygiene procedure to prevent the spread of infection to other . residents, . Between resident contacts . After handling items potentially contaminated with blood, body fluids .
On 01/30/19 at 3:50 PM, EI #1 was observed during a medication pass. The resident required an insulin injection. EI #1 applied gloves to her hands before giving the injection to the resident. After giving the injection EI #1 wore the gloves out of the room, went to the nurses station, reached into her front pocket for the keys to the nurses station and put the insulin pen back in the cart. She then removed the gloves and washed her hands.
On 01/30/19 at 5:05 PM, an interview was conducted with EI #1. She was asked what should she do after giving an injection, when wearing gloves, and before leaving the resident's room. EI #1 said take her gloves off and wash her hands. She was asked what should she have done after she removed her gloves. EI #1 replied washed her hands. She was asked did she walk down the hall with the dirty gloves on. EI #1 replied yes. EI #1 was asked what was the potential concern for walking down the hall with dirty gloves on. She replied spreading infection, infection control.
On 01/31/19 at 12:20 PM, an interview was conducted with EI #2, the infection control nurse. EI #2 was asked what should a nurse, wearing gloves, do before leaving a resident's room. She replied take the gloves off and perform hand hygiene before leaving the room. EI #2 was asked what was the potential concern for not removing gloves before leaving the residents room. EI #2 replied contamination.
This affected 1 of six residents observed during medication pass, conducted by 1 of three nurses, on 1/30/19.
Finding include:
The facility document titled, Hand Hygiene Policy copyright date 2018, included: . Staff involved in direct resident contact will perform proper hand hygiene procedure to prevent the spread of infection to other . residents, . Between resident contacts . After handling items potentially contaminated with blood, body fluids .
On 01/30/19 at 3:50 PM, EI #1 was observed during a medication pass. The resident required an insulin injection. EI #1 applied gloves to her hands before giving the injection to the resident. After giving the injection EI #1 wore the gloves out of the room, went to the nurses station, reached into her front pocket for the keys to the nurses station and put the insulin pen back in the cart. She then removed the gloves and washed her hands.
On 01/30/19 at 5:05 PM, an interview was conducted with EI #1. She was asked what should she do after giving an injection, when wearing gloves, and before leaving the resident's room. EI #1 said take her gloves off and wash her hands. She was asked what should she have done after she removed her gloves. EI #1 replied washed her hands. She was asked did she walk down the hall with the dirty gloves on. EI #1 replied yes. EI #1 was asked what was the potential concern for walking down the hall with dirty gloves on. She replied spreading infection, infection control.
On 01/31/19 at 12:20 PM, an interview was conducted with EI #2, the infection control nurse. EI #2 was asked what should a nurse, wearing gloves, do before leaving a resident's room. She replied take the gloves off and perform hand hygiene before leaving the room. EI #2 was asked what was the potential concern for not removing gloves before leaving the residents room. EI #2 replied contamination.