Failure to Follow Infection Control Protocols During Medication Administration and G-Tube Care
Penalty
Summary
A deficiency was identified when a Licensed Vocational Nurse (LVN) failed to perform proper hand hygiene during medication administration for a resident with multiple diagnoses, including dry eye syndrome, epilepsy, and Parkinson’s disease. The LVN did not sanitize or wash hands before entering the resident’s room, after exiting the room, before donning gloves, or after removing gloves, despite handling medications and administering eye drops. The LVN acknowledged the lapse in hand hygiene during an interview, and the facility’s policies clearly required hand hygiene at these points to prevent infection. Another deficiency was observed with a different resident who had a gastrostomy tube (G-tube) for enteral feeding and was dependent on staff for all activities of daily living. The resident’s [NAME] valve, used to maintain a closed system for tube feeding, was found to be uncapped, with visible dry, black, and brown crust and formula residue inside the connector port. The valve was only wrapped with a towel rather than being properly covered with a cap. Staff interviews confirmed that the valve should have been kept clean and covered, and that the facility had replacement covers available. The facility’s policies required proper cleaning and maintenance of medical devices to minimize infection risk. Both deficiencies were confirmed through direct observation, staff interviews, and review of facility policies and procedures. The failures to follow established infection prevention and control protocols placed the residents at risk for the spread of infection and cross-contamination. The facility’s own policies outlined the necessary steps for hand hygiene and device maintenance, which were not followed in these instances.