Failure to Follow Infection Control Practices During Medication Administration and Wound Care
Penalty
Summary
Staff failed to maintain proper infection control practices, specifically regarding hand hygiene and the use of personal protective equipment (PPE), during medication administration and wound care for three residents. The Director of Nursing (DON) was observed preparing and administering both oral and topical medications to two residents without washing hands or using hand sanitizer before or after the process, and confirmed during an interview that hand hygiene was not performed during these activities. Facility policy required hand hygiene before and after resident contact, after touching contaminated surfaces, and before moving between clean and soiled body sites, but these protocols were not followed. For one resident with multiple sclerosis, the DON prepared and administered 13 oral pills and a topical lidocaine patch without performing hand hygiene at any point before, during, or after the medication administration. The DON then proceeded to prepare medications for another resident without hand hygiene in between. Similarly, for another resident with multiple sclerosis, the DON prepared and administered oral medications without hand hygiene before or after the process, and then prepared a topical medication for the previous resident, again without hand hygiene. A third resident, who had multiple wounds and was on transmission-based precautions due to infection, received wound care from a registered nurse (RN) who did not wear an isolation gown as required and did not perform hand hygiene after removing a heavily soiled dressing and before applying a clean one. The RN confirmed the resident was on transmission-based precautions and acknowledged not using the appropriate PPE. Facility policies and CDC guidance required the use of gowns and hand hygiene in these situations, but these were not adhered to during the observed care.