Infection Control Lapses During Medication Administration
Penalty
Summary
The facility failed to maintain proper infection control practices during medication administration for three residents. In one instance, an LPN was observed administering medications to a resident with hypertension and did not clean the medication cart before preparing medications. A capsule was dropped onto the cart and then picked up with bare hands and placed into a medication cup. The LPN also handled and opened capsules without performing hand hygiene or wearing gloves. The LPN stated she did not consider a pill dropped unless it fell on the floor and routinely opened capsules without gloves. In another case, the DON administered insulin to a resident with diabetes but did not cleanse the hub of the insulin pen before attaching the needle, although she performed hand hygiene and donned gloves. Additionally, during medication administration for a resident with chronic obstructive pulmonary disease and chronic bronchitis, the DON failed to perform hand hygiene after contact with high-traffic surfaces and before entering the resident's room. The DON also touched and moved pills with a gloved finger after administering a nasal spray, without changing gloves or performing hand hygiene. Facility policies required hand hygiene before and after glove use and before resident contact, as well as cleansing the insulin pen hub prior to use, but these were not followed.