Failure to Follow Infection Control Standards During Medication Pass
Penalty
Summary
The facility failed to adhere to infection control standards during medication administration and the use of medical equipment for four out of five observed residents. Specifically, staff did not disinfect blood pressure cuffs or medication carts between resident uses, and medication containers were brought into resident rooms and handled by residents. These actions were observed during medication passes by two LVNs, who placed blood pressure cuffs back on the cart without cleaning and allowed medication boxes to be placed on bedside tables or handled by residents before returning them to the medication cart. Resident records indicated a range of medical conditions, including dementia, hypertension, renal insufficiency, diabetes, hyperlipidemia, anxiety, depression, mild cognitive disorder, seizure disorder, psychotic disorder, and anemia. The residents involved had varying levels of cognitive function, with some having moderate cognitive deficits and others having no cognitive impairment. Despite these differences, the same infection control lapses occurred across multiple residents. Interviews with the involved LVNs, the Nurse Manager, Director of Staff Development, and Infection Prevention Nurse confirmed that the observed practices were not in line with facility policy or infection control standards. All acknowledged that blood pressure cuffs and medication carts should have been disinfected between uses, and that medication boxes should not have been placed on resident furniture or handled by residents. The staff recognized these failures as infection control issues.