Failure to Follow Infection Control Protocols During Device Care and Medication Administration
Penalty
Summary
The facility failed to maintain a safe and sanitary environment to prevent the development and transmission of communicable diseases and infections, particularly for a resident with a feeding tube and during medication administration for two other residents. For the resident with a feeding tube, staff did not follow enhanced barrier precautions (EBP) as required. During a dressing change to the gastrostomy tube (g-tube) site, the LPN did not wear a gown as directed by EBP protocols, used the same pair of gloves throughout the procedure without changing them between dirty and clean tasks, and did not perform hand hygiene at appropriate intervals. The staff member acknowledged these lapses and confirmed awareness of the correct procedures, including the need to change gloves and perform hand hygiene between steps. Additionally, during medication administration for two residents, a Certified Medication Aide (CMA) failed to perform proper hand hygiene and gloving practices. The CMA did not sanitize hands after glove removal, between residents, or before entering a resident's room. The CMA also placed an eye drop bottle directly on a resident's bedside table without a barrier and carried used gloves from the resident's room to the medication cart before discarding them. These actions were contrary to facility policies and CDC guidelines, which require hand hygiene before and after resident care, after glove removal, and when moving between residents or care tasks. Facility policies reviewed included requirements for EBP, handwashing, and glove use, all of which were not followed during the observed incidents. The Director of Nursing confirmed the expectation that staff adhere to these protocols, including wearing gowns for high-contact activities involving medical devices, changing gloves, and performing hand hygiene at appropriate times. The observed failures represent a breakdown in infection prevention and control practices as outlined in facility policy.