Failure to Enforce Infection Control Policy for Visitor Access to Medication Cart
Penalty
Summary
During a medication pass observation, a visitor was seen taking multiple cups from the middle of a cup stack on top of the medication cart and pouring juice and water in the presence of an LVN. The LVN did not intervene or instruct the visitor that obtaining cups, juice, and water from the medication cart was not permitted. Shortly after, the same visitor was observed exiting a resident's room and returning to the medication cart to grab spoons, again without any staff intervention. The resident involved had been admitted with acute respiratory failure with hypoxia and type 2 diabetes mellitus. According to the facility's infection prevention policy, visitors and residents are not allowed to access items from the medication cart to prevent contamination, as their hand hygiene status is unknown. The infection prevention nurse confirmed that this practice is not allowed due to the risk of contamination, and the facility's policy requires education and instruction for residents, visitors, and volunteers on hand hygiene and infection control practices.