Infection Control Deficiencies in Medication Handling and Isolation Precautions
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by several deficiencies observed during a recertification survey. During a medication administration observation, an LPN handled medications with bare hands for a resident, which is a breach of infection control protocols. The LPN acknowledged the error but did not initially discard the contaminated medications. Additionally, another LPN failed to sanitize their hands after picking up an electrical cord from the floor before preparing medications for a resident, and an RN did not sanitize their hands before applying wound medication to a resident with pressure ulcers. The facility also failed to implement correct isolation precautions for a resident diagnosed with scabies. Incorrect signage was posted outside the resident's room, leading to confusion among staff about the necessary precautions. The Director of Nursing Services, responsible for posting the signage, admitted the error, and staff interviews revealed a lack of understanding of the differences between Enhanced Barrier Precautions and contact isolation precautions. This miscommunication could have led to inadequate protection for staff and visitors entering the resident's room. Furthermore, the facility did not maintain cleanliness in the medication storage areas. An observation revealed that the medication refrigerator in one unit had dirty drug labels and debris, which the nursing staff failed to address. The Director of Nursing Services confirmed that the nursing staff was responsible for ensuring the cleanliness of the medication refrigerator, and the presence of debris could pose an infection control risk due to potential contamination of stored medications.
Plan Of Correction
Plan of Correction: Approved April 15, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** I. Immediate Corrective Action - Resident #32: Medications dispensed by hand were discarded immediately upon identification, and a new, properly handled dose was administered. Licensed Practical Nurse #1 received immediate re-education on infection control standards during medication administration. - Resident #133: The Enhanced Barrier Precautions (EBP) signage was removed and replaced with the correct Contact Isolation signage per physician order [REDACTED]. - Resident #50: Registered Nurse #3 was re-instructed on proper hand hygiene protocols. Resident’s wound site was reassessed with [REDACTED]. No harm identified. - Unit 4 Medication Refrigerator: The medication refrigerator was immediately cleaned and disinfected. All outdated or damaged labels were removed, and the area was sanitized according to facility policy. RN Supervisor was counseled on proper oversight. - Resident #3: Licensed Practical Nurse #2 sanitized their hands after being prompted by the surveyor. Nurse was immediately reminded of hand hygiene protocol prior to medication handling. II. Identification of other residents - Any resident receiving wound care and/or medication has the potential to be affected by this deficiency. - All residents on any level of Infection Control Precautions were assessed for the correct signage on their room door. - All signage matched the physicians’ orders. - All medication storage room refrigerators were assessed and found to be clean. III. Systemic Changes - The facility policies titled Medication Administration Guidelines, Pressure Injury/Pressure Ulcer Assessment, Prevention and Management, Infection Prevention Control Program, Contact Precautions, Enhanced Barrier Precautions and Medication Refrigerator Cleaning were reviewed and found to be in compliance with the regulations. - All licensed nurses will be educated on proper infection prevention policies and practices during medication administration and wound treatment, as well as medication storage room refrigerator cleaning procedures. - The Infection Preventionist will be educated on utilizing precaution signage according to physician’s orders. - A copy of the attendance sheet will be filed for reference and validation. IV. QA Monitoring - Existing medication pass and wound treatment competencies will be used to audit infection prevention/control practices during these service provisions. Each licensed nurse will be assessed monthly for three months. - An Audit Tool has been developed to monitor the placement of appropriate infection precaution signage on resident room doors. An Audit Tool has been developed to assess the cleanliness of medication storage room refrigerators. - Five licensed nurses will be audited weekly for one month using the two audits (Medication Pass and Wound Treatment Competencies). Further audits will be conducted on 5 nurses monthly for 2 months. - The placement of appropriate infection precaution signage on resident room door will be audited weekly for one month, then monthly for 2 months. - The cleanliness of medication storage room refrigerator will be audited weekly for one month, then monthly for 2 months. - Audit findings will be compiled, analyzed and brought to the QAPI Committee. - During the quarterly QAPI Committee meeting, the audit results will be reviewed and assessed for continuance, based on compliance and incidence of negative findings. Responsible Party: Director of Nursing