Failure to Follow Infection Control and Enhanced Barrier Precautions During Resident Care
Penalty
Summary
A deficiency was identified when a registered nurse administered medication to a resident without following proper infection control practices. Specifically, the nurse used her bare fingers to extract Lyrica from its packaging and placed it into the resident's medication cup, which was then consumed by the resident. The nurse confirmed this action during an interview immediately following the observation. In another instance, a resident with a percutaneous endoscopic gastrostomy (PEG) tube had a physician's order for Enhanced Barrier Precautions (EBP), requiring gown and glove use during high-contact care activities. Despite this order, there was no evidence of EBP implementation, such as PPE carts, signage, or soiled linen bins in the resident's room. The unit manager confirmed that EBP was not in place, even though the resident had an indwelling medical device and the facility's policy required EBP for such cases. A third deficiency involved a resident with a urinary catheter and wounds, who also had a physician's order for EBP. During wound care, neither the registered nurse nor the unit manager wore gowns as required, and there was no EBP signage or PPE cart present. Both staff members confirmed that EBP was not followed during the care activity, despite the facility's policy and physician's order indicating its necessity for residents with indwelling devices or wounds.