Infection Control Deficiencies in Medication Administration and Wound Care
Penalty
Summary
The facility failed to maintain proper infection control practices and procedures, as evidenced by observations during a recertification survey. Specifically, three Licensed Practical Nurses (LPNs) did not adhere to Enhanced Barrier Precautions while administering medications and performing wound care. LPN #2 administered intravenous medications to a resident with a Peripherally Inserted Central Catheter without wearing a gown, despite the resident being under Enhanced Barrier Precautions. LPN #2 was unaware of the need for a gown due to a lack of education on Enhanced Barrier Precautions. Similarly, LPN #3 administered medications through a Gastrostomy tube to another resident without donning a gown. This resident was also under Enhanced Barrier Precautions, as indicated by signage on the resident's door and personal protective equipment cart. LPN #3 failed to notice the signage and did not follow the required precautions. Additionally, LPN #1 did not establish a clean field for wound care supplies and failed to perform hand hygiene after removing soiled dressings during a dressing change for a resident with multiple ulcers. LPN #1 admitted to omitting critical infection control steps due to nervousness during the procedure. These lapses in infection control practices were observed despite the facility's policies and procedures outlining the necessary precautions and steps for medication administration and wound care.
Plan Of Correction
Plan of Correction: Approved March 4, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 1. What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? Resident #389 has no negative outcome as evidenced by no signs and symptoms of infection of IV site and wound. Resident #63 has no negative outcome as evidenced by no signs and symptoms of infection of [DEVICE] site. LPN #2 & LPN #3 were in serviced on enhanced barrier precaution policy and procedure on 2/6/2025. LPN #1 was in serviced on dressing dry clean policy and procedure on 2/27/2025. 2. How you will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken? - All residents have the potential to be affected by this practice. - All residents with wounds and EBP are being reassessed to ensure no deficient practice occurs. Any outstanding issues will be addressed immediately. 3. What measures will be put in place or what systemic changes you will make to ensure that the deficient practice does not recur? - The facility Policy on enhanced barrier precautions was reviewed and no revision needed. - All staff is being re-educated on enhanced barrier precaution. - EBP competency test is being administered to clinical staff and implemented as part of orientation and annual training. - All nurses are being re-educated on dressing change policy and procedure with emphasis on establishing a clean field for placement of wound supplies and hand hygiene. - Wound Dressing Change observation is being implemented to the orientation and thereafter annually. - Audit tools are being developed for enhanced barrier precaution and wound dressing dry clean. 4. How the corrective action(s) will be monitored to ensure the deficient practice will not recur? - On a weekly basis for the first quarter, the director of nursing or designee will conduct an audit of 2 to 4 employees caring for residents on enhanced barrier precaution for compliance. Any outstanding issues will be corrected immediately and reported to the administrator. - On a weekly basis for the first quarter, the director of nursing or designee will conduct treatment observation on 1 nurse for proper dressing change including surface preparation and hand hygiene. - On a monthly basis, the Director of Nursing will report the findings to the Administrator. - On a quarterly basis, the Director of Nursing will report findings to QAPI Committee. - QAPI Committee to determine if further action is required. 5. The title of the person responsible for correction of each deficiency: Director of Nursing & Asst. Dir of Nursing.