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F0880
D

Failure to Follow Infection Control Protocols During Medication Administration

Brooklyn, New York Survey Completed on 05-29-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

A deficiency was identified when a Licensed Practical Nurse (LPN) failed to adhere to infection control protocols during medication administration to a resident with a gastrostomy tube. The LPN did not perform hand hygiene before donning gloves to prepare medications, picked up a medication that had fallen on the floor with the same gloved hands, and continued to administer medications without changing gloves or performing hand hygiene. Additionally, the LPN did not don the required personal protective equipment (PPE) before entering the resident's room, despite signage indicating the need for Enhanced Barrier Precautions. Interviews revealed that the LPN was newly hired and had received orientation and in-service education on infection prevention, including hand hygiene and Enhanced Barrier Precautions. The LPN stated they did not notice the signage or the availability of PPE supplies near the resident's room. Facility leadership confirmed that infection control education and signage were in place and that supplies were accessible, but the LPN did not follow established protocols during the observed medication administration.

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