Failure to Follow Enhanced Barrier Precautions During Medication Administration
Penalty
Summary
A deficiency was identified when a registered nurse failed to follow infection control measures during medication administration for a resident with multiple risk factors for infection, including bacteremia, end stage renal disease, and a central venous catheter (CVC). The resident's care plan and physician orders required the use of enhanced barrier precautions (EBP), specifically gown and glove use, during high-contact care activities due to the presence of indwelling medical devices and an open wound. Despite these documented requirements, the nurse administered oral medications by popping them into her bare hands and then into a medication cup, and subsequently administered intravenous antibiotics through the resident's CVC without wearing a gown as required by EBP protocols. The nurse confirmed during an interview that she did not use gloves when handling the medications and did not wear a gown while administering the IV antibiotics. Review of the facility's policy on enhanced barrier precautions indicated that gown and glove use is mandatory during high-contact care activities for residents at increased risk of multidrug-resistant organism (MDRO) acquisition, including those with wounds or indwelling devices. The failure to adhere to these infection control measures was observed and verified through staff interview and policy review.