Infection Control Breach During Medication Administration
Penalty
Summary
The facility failed to adhere to proper infection control practices during medication administration for one resident. Specifically, a Licensed Practical Nurse (LPN) was observed administering a 5 mg tablet of amlodipine, a medication used to treat high blood pressure, to a resident after it had been dropped on the medication cart. The LPN picked up the tablet with her bare hands and proceeded to give it to the resident, which is against the facility's infection control protocols. The incident occurred on February 5, 2025, and involved Resident 41, who had a physician's order for amlodipine that had been discontinued the previous day. The LPN confirmed during an interview that she should not have handled the medication with her bare hands. The Nursing Home Administrator also confirmed that staff are instructed not to touch residents' medications with their bare hands, indicating a breach in the facility's infection prevention and control program.
Plan Of Correction
1. Resident 41 was assessed and no harm suffered from ingesting the touched pill. 2. Any resident has the potential to be affected by this deficient practice. 3. Nurses have been re-educated on the policy of not touching medication with bare hands. Three nurses will be observed each week doing a medication pass for one resident each. This audit will be done weekly x 4 and then monthly x2 and reported to the Quality Assurance team for review. Director of Nursing or designee will monitor.