Failure to Implement Infection Control Practices During Medication Administration and Resident Care
Penalty
Summary
The facility failed to implement appropriate infection prevention and control practices during medication administration and resident care. Observations included staff not disinfecting medical equipment, such as blood pressure cuffs, before use on different residents, and not following proper hand hygiene protocols after glove removal. In one instance, an LPN used a blood pressure machine on a resident without disinfecting it beforehand, despite acknowledging that equipment should be cleaned before and after use. Another staff member entered the room of a resident on Enhanced Barrier Precautions (EBP) without donning the required gown, only wearing gloves and a mask, and placed medical equipment on the bedside table before use. The same staff member only disinfected the equipment after use, not before, and did not adhere to the manufacturer’s recommended contact time for disinfectant wipes. Additional deficiencies were observed in the handling and storage of medical equipment and supplies. A urinary drainage bag with visible sediment was found hanging over a grab bar next to a dirty emesis basin in a resident's bathroom, contrary to facility policy. The emesis basin was visibly soiled with dried toothpaste. In another case, a nebulizer mask and tubing were left attached to the machine on a nightstand rather than being stored in a plastic bag as required. Staff interviews confirmed that nebulizer equipment should be rinsed, air-dried, and stored in a plastic bag when not in use, but this was not consistently practiced. The facility's own policies require the use of PPE, including gowns and gloves, for high-risk activities with residents on EBP, and mandate cleaning and disinfecting shared medical equipment between residents. Policies also specify that hand hygiene must be performed after glove removal and that nebulizer equipment should be properly cleaned and stored. Despite these policies, staff did not consistently follow these procedures, as evidenced by direct observation and staff interviews. Several residents, including those with complex medical needs such as urinary catheters, colostomies, and respiratory treatments, were affected by these lapses in infection control.