Failure to Implement and Maintain Infection Control and Isolation Precautions
Penalty
Summary
The facility failed to ensure proper infection prevention and control practices were followed by staff during medication administration and the maintenance of isolation precautions. Specifically, a nurse administered medications and provided midline catheter care to a resident on enhanced barrier precautions (EBP) without donning an isolation gown, despite signage indicating the need for EBP and a care plan requiring staff to follow EBP protocols. The nurse acknowledged awareness of the requirement but cited the absence of gowns in the isolation cart as the reason for non-compliance. Another nurse was observed preparing medication for a resident with a gastric feeding tube by breaking open a capsule with bare hands, rather than using gloves. The nurse stated she was instructed not to wear gloves in the hallway, but also acknowledged that medications should not be handled with bare hands. The Director of Nursing confirmed the expectation that medication preparation occurs outside the resident's room without gloves, but that gloves should be used when direct contact with medications is necessary, and this should occur inside the resident's room. Additionally, the facility failed to maintain required isolation precautions for a resident with a midline catheter and orders for both contact/droplet and enhanced barrier precautions. Observations revealed the absence of isolation signage and an isolation cart outside the resident's room, despite active orders documented in the medical record. Staff continued to sign off on isolation precautions in the medication administration record even when the orders were not in place, and there was a lapse in re-establishing precautions after the midline was replaced.