Failure to Follow Infection Control Procedures During Medication and Wound Care
Penalty
Summary
Surveyors identified that the facility failed to follow proper infection control procedures during medication administration and wound care for three residents. During a medication pass, a licensed employee placed medication pills into their ungloved hands before transferring them to a medication cup, contrary to the facility's policy requiring adherence to infection control practices such as hand hygiene and glove use. For residents with pressure ulcers, there was no system in place to communicate the need for enhanced barrier precautions to staff, and personal protective equipment (PPE) was not readily available in the rooms of affected residents. Observations revealed that staff did not use PPE during wound dressing changes for residents with stage II and stage III pressure ulcers. Additionally, there were no visible indications or signage in the rooms to alert staff to the required precautions. Clinical record reviews confirmed the presence of pressure ulcers in the affected residents, and direct observations documented repeated failures by staff to utilize PPE during wound care. These lapses were observed and reported to facility leadership during the survey, highlighting a breakdown in the implementation of the facility's infection prevention and control program as required by regulation.
Plan Of Correction
E9 had a medication competency completed. R6, R22, R136 were placed on Enhanced Barrier Precautions. PPE and signage were placed for each resident. Residents requiring Enhanced Barrier Precautions related to pressure injuries were reviewed for proper signage, and PPE was available. Education will be completed by the DON/designee for all direct care staff and the interdisciplinary team on Enhanced Barrier Precautions use for Pressure Injuries. Licensed staff will be educated on following infection control practices during medication administration. The DON/designee will audit 5 residents that require Enhanced Barrier Precautions weekly for 4 weeks, then monthly for 2 months to ensure precautions are being utilized, proper PPE is available, and signage is posted for all pressure injuries/wounds. Five medication administration audits will be completed for 4 weeks, then monthly for 2 months. The results of the audits will be reviewed by the Quality Assessment and Assurance Committee for the need to complete further audits. F 0880