Infection Control Breach During Medication Administration
Penalty
Summary
During a recertification survey, a deficiency was identified in the facility's infection prevention and control program. Specifically, a registered nurse was observed handling oral medication tablets with bare hands during medication administration for a resident. The nurse placed the medications on an unsanitized overbed table without a barrier, touched each medication with bare hands while explaining them to the resident, and then administered the medications. This action was contrary to the facility's policy, which requires following infection control protocols and not touching medications with bare hands. The resident involved was cognitively intact and had diagnoses including Diabetes Mellitus, Cerebrovascular Accident, and Depression. The facility's policies on medication administration and infection control were not adhered to, as confirmed by interviews with the Registered Nurse Inservice Coordinator, the Director of Nursing Services, and the Registered Nurse Infection Preventionist. All agreed that handling medications with bare hands was unacceptable and that there are alternative methods to explain medications to residents without direct contact.
Plan Of Correction
Plan of Correction: Approved January 10, 2025 I. The following actions were accomplished for those residents found to have been affected by the deficient practice: Resident #48 On 12/11/24, the resident was evaluated by the Physician who determined that the resident exhibited no signs or symptoms of an infection following consuming medications that the nurse had handled with her bare hands. RN #1 On 12/5/24, the Staff Educator provided education to RN #1 related to general principles of infection control related to medication administration include not touching a resident’s medication with the nurse’s bare hands. II. The following corrective actions will be implemented to identify other residents having the potential to be affected by the same deficient practice: All residents have been identified as potentially being affected by the same practice. Effective 12/5/24, all licensed nurses, who are responsible for medication administration, will have a medication administration competency, including an assessment of the staff member’s infection control practices and management of a resident’s medication without touching the medication with their bare hands during administration, completed by the Staff Educator/designee. III. The following system changes will be implemented to ensure that the deficient practice does not recur: On 12/18/24, the Administrator, Medical Director, Chief Nursing Officer and Infection Preventionist reviewed the policy and procedure for medication administration and associated infection control practices related to medication management and not handling a resident’s medication during the administration process. The Staff Educator will conduct additional medication administration competency skill evaluations, that includes a review of acceptable infection controls that the nurse must adhere to when administering medication for any licensed nurse who did not successfully pass the initial medication competency completed for all nurses responsible for medication administration as outlined above in Section II. Medication administration competencies will continue to be included in the licensed nurses’ orientation and will be reviewed on an as needed basis. Inservice education on general infection control practice will continue to be provided annually. Licensed nurses’ infection control education will include standards of practice associated with medication administration. The Infection Preventionist and Nursing Supervisors will monitor for compliance with general infection control practices including protocols related to medication administration during routine and random rounds on the resident units. Findings will be documented on the Infection Control Rounding audit tool. Immediate corrective actions, such as counselling or reeducating staff, will be implemented as needed. IV. The facility’s compliance will be monitored utilizing the following quality assurance system: The Staff Educator/designee will audit 5 licensed nurses during medication administration for compliance with hand hygiene and infection control practices weekly for one month then 10 licensed nurses monthly for the next two months and then on a quarterly basis for the next two quarters. Licensed nurses from all shifts will be included in the audit sample. All audit findings will be reported to the Administrator and Chief Nursing Officer. Additional corrective action, such as staff reeducation or competency retesting, will be implemented as indicated. The Infection Preventionist will continue to conduct routine weekly Infection Control Rounds and will report findings from rounds, infection control rates and other pertinent infection control data to the QAPI Committee, minimally, on a quarterly basis for discussion, evaluation and follow-up corrective actions. Completion Date: 01/31/2025 Responsibility: Infection Preventionist