Failure to Implement Infection Control Practices During Medication Administration and LVAD Dressing Change
Penalty
Summary
The facility failed to implement appropriate infection prevention and control practices during medication administration, medication storage, and a sterile dressing change for two residents. During medication administration, a registered nurse picked up a tablet that had fallen onto the medication cart surface with a gloved hand and returned it to the medication cup, then continued preparing and administering medications without sanitizing the cart immediately prior to use. Additionally, an audit of the medication cart revealed the presence of an open energy drink and an open bag of pretzels stored in the cart, contrary to facility expectations that no food or beverages be stored with medications. For a resident with multiple diagnoses including end stage heart failure, cirrhosis of the liver, and immunodeficiency, staff failed to follow sterile technique during a dressing change for a Left Ventricular Assist Device (LVAD). The nurse placed the dressing package directly on the bed without a barrier, did not establish a sterile field, and performed the dressing change using clean rather than sterile technique, despite facility policy and the LVAD Management Manual requiring sterile procedures for such dressing changes.