Infection Control Lapses During Medication Administration and Wound Care
Penalty
Summary
Staff failed to adhere to infection prevention and control protocols during medication administration and wound care for several residents. Specifically, a registered nurse did not perform hand hygiene after administering medications to one resident and before donning gloves to check another resident's blood sugar. The same nurse also failed to clean and disinfect the glucometer after use and did not don gloves or perform hand hygiene prior to administering insulin injections to two residents. These lapses occurred despite the facility's policy requiring hand hygiene before and after resident contact, after glove removal, and after contact with potentially contaminated equipment. Additionally, a licensed practical nurse did not perform hand hygiene before administering medications to a resident, immediately after completing medication administration for another resident. This was confirmed during an interview with the nurse, who acknowledged the failure to follow hand hygiene protocols as outlined in facility policy. During wound care for a resident with severe edema, multiple sores, and a physician order for enhanced barrier isolation precautions, another licensed practical nurse failed to don a gown as required. The nurse confirmed during an interview that a gown should have been worn for the procedure. Facility policies and CDC guidelines reviewed by surveyors emphasized the importance of cleaning and disinfecting shared medical equipment and using appropriate personal protective equipment (PPE) during high-contact care activities, especially for residents with wounds or indwelling devices.