Failure to Follow Infection Control Practices During Medication Administration and Incontinence Care
Penalty
Summary
A deficiency was identified when a Licensed Practical Nurse (LPN) failed to follow proper infection control practices during medication administration for a resident with organ-limited amyloidosis, vascular dementia, and acute kidney failure. The LPN prepared the resident's medications, and when two pills were dropped on the floor, she picked them up with her bare hands and discarded them. Without performing hand hygiene, she proceeded to open the medication cart, prepare replacement medications, and administer them to the resident, all without washing her hands or using hand sanitizer at any point during the process. The LPN confirmed in an interview that she did not perform hand hygiene after handling the dropped pills or before handling the medication cart and administering the medications. Another deficiency was observed during incontinence care for a resident with anoxic brain damage, benign intracranial hypertension, hemiplegia, and hemiparesis, who was dependent on staff for all activities of daily living and was always incontinent. A Certified Nursing Assistant (CNA) providing care threw the resident's soiled bed linens, towels, and urine-saturated incontinence brief directly onto the floor instead of placing them in a plastic bag or appropriate container. The soiled items remained on the floor during care, and the CNA acknowledged in an interview that this action could cause cross contamination. Facility policy requires hand hygiene before and after direct resident contact, before handling medications, and after handling soiled linens, but these procedures were not followed.