Failure to Follow Infection Control Protocol During IV Medication Administration
Penalty
Summary
A deficiency was identified when a nurse failed to follow infection prevention and control standards during the administration of intravenous (IV) medication to a resident with a peripherally inserted central catheter (PICC) line. The nurse was observed washing her hands, donning a gown and gloves, and preparing the IV medication. However, after putting on gloves, she touched the resident's divider curtain and the IV pump, then continued with the procedure without changing gloves or performing hand hygiene before accessing the resident's PICC port. This action was contrary to facility policy, CDC guidelines, and WHO recommendations, all of which require hand hygiene and the use of clean gloves before handling invasive devices or after contact with potentially contaminated surfaces. The resident involved had a history of sepsis, pneumonia, diabetes, and was being treated for osteomyelitis with IV vancomycin via a PICC line. The nurse's failure to change gloves or perform hand hygiene after touching inanimate objects in the resident's environment and before accessing the PICC port was confirmed through observation and staff interview. The nurse acknowledged the lapse in infection control practices, and the Chief Nursing Officer confirmed that proper hand hygiene and glove use are required before accessing IV sites.