Failure to Maintain Infection Control During Medication Administration and Housekeeping
Penalty
Summary
The facility failed to maintain proper infection prevention and control practices for five of 31 sampled residents, as evidenced by multiple staff not performing required hand hygiene during medication administration, meal service, and housekeeping tasks. During medication administration, one LPN was observed with an open can of soda on top of the medication cart, which she acknowledged was her personal drink and should not have been there. Another LPN was observed administering medications to three residents consecutively without performing hand hygiene between residents, which she confirmed was not in accordance with facility policy. Further deficiencies were observed in the care of residents on Enhanced Barrier Precautions. A housekeeper was seen cleaning the room of a resident with an unstageable chronic wound and then, without performing hand hygiene after glove removal, proceeded to clean another resident's room. The housekeeper acknowledged not following the posted hand hygiene instructions. Additionally, an LPN preparing to provide wound care for a resident on Enhanced Barrier Precautions exited and re-entered the room without performing hand hygiene before donning new PPE and completing the dressing change, which the LPN later confirmed was an error. The residents involved had varying medical conditions, including alcohol-induced persisting dementia, chronic pancreatitis, urinary tract infection, and a progressive neurological disease. Some residents were severely or moderately cognitively impaired, while others were cognitively intact. The facility's own policies required hand hygiene before and after medication administration, after glove removal, and when entering or leaving rooms under Enhanced Barrier Precautions, but these protocols were not consistently followed by staff.