Failure to Maintain Infection Control in Ostomy Care and Medication Handling
Penalty
Summary
The facility failed to ensure proper infection prevention and control practices in several instances. For one resident with a colostomy, an LPN removed a soiled colostomy bag, discarded it, and then, unable to find a suitable replacement, retrieved the soiled bag from the garbage, rinsed it with mouthwash, wiped it with bleach, and reapplied it to the resident. The LPN did not seek assistance or check the supply room for the correct supplies, despite multiple sizes of ostomy supplies being available in stock. The resident reported feeling nervous about the incident, although no pain or discomfort was noted. Additionally, during medication administration, an LPN placed a used glucometer on top of the medication cart and then stored it in the cart drawer without cleaning it. Observations of two medication carts revealed that multiple insulin pens were stored unbagged together, posing a risk for cross-contamination. Staff interviews confirmed that proper infection control procedures were not consistently followed, and the Director of Nursing acknowledged the failure to prevent cross-contamination and ensure proper infection control practices.