Infection Control Deficiency in Medication Administration
Penalty
Summary
The facility failed to maintain an effective infection control program during the preparation and administration of medications for three residents. The facility's policy on medication administration requires staff to adhere to good hand hygiene, including washing hands before beginning a medication pass, prior to handling any medication, and after coming into direct contact with a resident. However, during a medication pass observation, Employee 2 did not follow these guidelines. After administering an insulin injection to Resident 9, Employee 2 did not cleanse her hands before preparing medications for Resident 27. Employee 2 also failed to follow proper infection control procedures when performing a blood glucose test for Resident 27. She used her gloved hand to close a window and then proceeded with the test without changing gloves. Additionally, she did not properly clean the glucometer according to the facility's policy, which requires cleaning and disinfecting the device after each use. Employee 2 was unsure of the correct cleaning procedure and used an alcohol pad instead of the required germicidal disposable wipe. Furthermore, Employee 2 did not adhere to Enhanced Barrier Precautions (EBP) when attending to Resident 155, who had a central line. Despite the EBP sign indicating the need for hand cleansing and wearing gloves and gowns, Employee 2 entered the room without cleansing her hands and did not wear a gown while flushing the central line. These actions were confirmed by the Nursing Home Administrator and Director of Nursing, who acknowledged the expectation for staff to follow personal protective equipment guidance and hand hygiene protocols.
Plan Of Correction
1. DON will provide education to Employee 2 on infection control practices during medication administration to ensure all infection control procedures are being followed. 2. DON will provide education to Employee 2 on Enhanced Barrier precautions for gown and gloves when giving care to an individual on these precautions. 3. DON will provide education to Employee 2 on proper cleaning and disinfecting of glucometers after each use. 4. DON will provide education to nursing staff on infection control practices during medication passes, Enhanced Barrier Precautions, and proper glucometer disinfecting. 5. Resident's 9, 27 and 155 were all assessed for any adverse effects regarding nonadherence to infection control practices and enhanced barrier precautions. 6. All other residents on Employee 2's medication pass were assessed for any adverse reactions related to not following infection control practices and enhanced barrier precautions. 7. DON/ designee will conduct an audit 2 times a week x 4 weeks on via direct observation of a medication pass, then monthly x 2 months. 8. All findings will be taken to QAPI for review.