Infection Control and PPE Deficiencies During Medication Administration and Resident Care
Penalty
Summary
Surveyors identified multiple deficiencies in the facility's infection prevention and control practices. During medication administration, a nurse dropped a tablet of Levothyroxine for a resident with thyroid disease and heart failure, picked it up with an ungloved hand, and placed it back into the medication cup, contrary to facility policy and infection control standards. The facility's policy directed that gloves should be worn when handling tablets to prevent contamination, but this was not followed. For a resident with epilepsy, bullous pemphigoid, and a Foley catheter, staff failed to adhere to Enhanced Barrier Precautions (EBP) as ordered by the physician. Observations revealed that staff and hospice personnel did not consistently wear required PPE, such as gowns and gloves, when providing direct care. In one instance, a nurse replaced a dirty glove that had fallen off during wound care without performing hand hygiene or changing to a clean glove, despite being aware of the correct procedure. Hospice staff also failed to don appropriate PPE, either due to not noticing posted signage or not following instructions, even when providing direct care to the resident. Additionally, a resident with a wound and indwelling urinary catheter was observed receiving care from an occupational therapist who did not wear a gown as required by EBP, only donning gloves. The therapist was unaware that a gown was necessary for direct care. The medication room was also found to be cluttered and dirty, with items stored in the sink's splash zone and insufficient space for medication preparation. Facility policies did not specify procedures or responsibilities for maintaining a clean medication room, contributing to the unsanitary conditions observed.