Failure to Follow Infection Control Precautions During Resident Care and Medication Administration
Penalty
Summary
Multiple infection control deficiencies were observed involving three residents. For one resident with a history of multiple drug-resistant organisms and on enhanced barrier precautions, a CNA was seen placing a wet towel on a dirty chux, cleaning the resident’s rectum from back to front with the same towel, and returning a pillow and bed linen that had fallen on the floor to the resident’s bed. The CNA also failed to change gloves or perform hand hygiene after providing perineal care and did not remove personal protective equipment before leaving the resident’s room. These actions were confirmed by both the CNA and a treatment nurse present during the incident, who stated that proper procedures were not followed, including the use of clean linens and correct hand hygiene practices. Another resident, who was dependent on staff for all activities of daily living and received medications via a gastrostomy tube, was involved in an incident where an LVN prepared and administered medications using a syringe. The LVN left the resident’s bedside with the used syringe, walked to the medication cart, and then returned to continue medication administration with the same syringe, exposing it to environmental contamination. The LVN acknowledged that this practice was incorrect and could lead to contamination, and the DON confirmed that such actions increase the risk of infection. A third resident, who required assistance with activities of daily living and was prescribed artificial tears, was observed receiving eye drops from an LVN who did not perform hand hygiene after preparing medications, before donning gloves, or prior to administering the eye drops. The LVN later stated that hand hygiene should have been performed to prevent contamination and infection. Facility policies reviewed indicated that hand hygiene is required before and after direct resident care, after glove removal, and before medication administration, but these protocols were not followed during the observed incidents.