Infection Control Breach During Medication Administration
Penalty
Summary
The facility failed to adhere to infection prevention and control practices during medication administration for two residents. On December 19, 2024, at 9 A.M., an LPN administered over-the-counter medications to a resident by pouring pills into her ungloved hand, transferring them into a plastic medication cup, and handing the cup to the resident. The medications included Vitamin B1, Vitamin B12, and a multi-vitamin. At 9:05 A.M., the same LPN repeated this practice with another resident, administering a multi-vitamin and Vitamin B1. Additionally, the LPN dropped a capsule on the top of the medication cart, picked it up with her ungloved hand, placed it into a plastic medication cup, and provided it to the resident. During an interview on December 20, 2024, the Director of Nursing confirmed that these practices constituted a breach of infection control standards during medication administration. The facility's failure to follow proper infection control practices placed residents at increased risk of infection and compromised their safety.
Plan Of Correction
1. R-57 & R-34 had no ill effects from incorrect handling of the OTC/vitamins during the medication pass on December 19, 2024. 2. Employee 1 received 1:1 education on proper medication handling and administration of any OTC/vitamin. Education to remaining LPN/RN's on proper medication handling and administration of any OTC/vitamin. 3. Audit(s) will be conducted on correct medication administration of OTC/vitamins three times per week for 4 weeks; weekly times 4 weeks and randomly for 4 weeks. 4. Results of the medication audits will be submitted to the QA Committee for three months.