Failure to Follow Infection Control and Medication Administration Protocols
Penalty
Summary
The facility failed to maintain proper infection prevention and control practices for two residents. In the first instance, two CNAs provided peri-care and catheter care to a male resident with dementia, a urinary tract infection, and an indwelling catheter, who was on enhanced barrier precautions (EBP). Despite clear care plan instructions and posted signage requiring both gloves and gowns for such care, the CNAs only donned gloves and omitted gowns. Both staff members acknowledged their training on EBP and recognized their failure to follow protocol during interviews. The Director of Nursing confirmed that the CNAs had been trained and should have worn both gloves and gowns during the procedure. In the second instance, an LVN administered insulin Lispro to a male resident with diabetes using an insulin pen labeled for a different resident. The LVN explained that the resident's own supply of insulin was depleted and, after checking for additional stock and finding none, used another resident's pen because it contained the same medication. The LVN sanitized the pen, attached a new needle, and wrote the receiving resident's name on the cap. The Regional Compliance Nurse, upon review, stated that insulin pens should not be shared between residents, even if the medication is the same, due to the risk of cross-contamination and medication tracking issues. Facility policy also prohibits administering medications prescribed for one resident to another. Both deficiencies were observed directly by surveyors and confirmed through interviews and record reviews. The facility's own policies on enhanced barrier precautions and medication administration were not followed in these instances, as evidenced by staff actions and subsequent staff and management interviews.