Failure to Use Enhanced Barrier Precautions During Medication Administration
Penalty
Summary
The facility failed to utilize enhanced barrier precautions during medication administration for a resident with a feeding tube. The facility's policy for Enhanced Barrier Precautions, revised in March 2024, requires the use of gown and gloves during high-contact resident care activities, such as device care or use, to reduce the transmission of multi-drug-resistant organisms. However, during an observation of medication administration, a Licensed Practical Nurse (LPN) did not don a gown and gloves while providing care to the resident's percutaneous endoscopic gastrostomy (PEG) tube. The resident involved was admitted to the facility with oropharyngeal dysphagia and malnutrition, requiring a gastrostomy tube for nutrition, fluids, and medications. The resident's care plan specifically required the use of gloves and gown during high-contact care activities involving the feeding tube. Despite these requirements, the LPN failed to adhere to the facility's infection prevention and control program, as evidenced by the lack of appropriate protective equipment during the observed medication administration.
Plan Of Correction
1. R105 no longer resides in the center. No adverse effects were noted. 2. An initial audit was conducted to validate EBP's are utilized during medication administration via feeding tube. Variances were addressed at the time of the audit and placed on the facility audit tool. 3. DON/Designee will re-educate all licensed nurses on utilizing EBP's during medication administration via feeding tube. 4. DON/Designee will conduct random audits to validate EBP's are utilized during medication administration via feeding tube 3 times per week for 4 weeks then 1 time a month for 2 months. Audit findings will be addressed and submitted to the Quality Assurance Performance Improvement Committee for further review and recommendations as needed.