Failure to Implement Infection Control Measures for Isolation Precautions and Medication Pass
Penalty
Summary
Facility staff failed to implement required infection control measures for a resident on contact isolation precautions. Observations revealed that staff entered the resident's room without donning gowns or gloves, handled the resident and their personal items, and removed soiled linens with bare hands. Staff did not perform hand hygiene after leaving the isolation room and were seen carrying used linens down the hall. The Infection Preventionist confirmed that these actions did not comply with the facility's contact isolation protocols, which require the use of personal protective equipment and hand hygiene after resident contact and PPE removal. Additionally, during a medication pass, a nurse was observed pouring tablets from blister packs directly into his ungloved hand and then placing the medications into cups for administration to two residents. The nurse did not perform hand hygiene between medication administrations. In an interview, the nurse acknowledged these actions and stated he believed gloves were not permitted in the hallway. These practices were not consistent with infection control standards for medication administration.