Failure to Follow Infection Control and Enhanced Barrier Precautions
Penalty
Summary
Staff failed to follow infection prevention and control protocols during multiple observed care activities. A registered nurse was observed dropping a resident's medication onto a report sheet, picking it up with ungloved hands, and administering it to the resident without discarding the contaminated pill. The nurse later acknowledged that gloves or a spoon should have been used and that the medication should not have been touched by hand. The Director of Nursing confirmed that the correct procedure would have been to discard the pill and obtain a new one. Additionally, staff did not perform appropriate hand hygiene during medication pass, as observed during the survey. Enhanced Barrier Precautions (EBP) were not utilized as required during wound care and catheter care for two residents. One resident with an indwelling catheter and an order for EBP was cared for by a CNA who did not wear a gown while draining the catheter, contrary to facility expectations. Another resident with a Stage 3 pressure ulcer and on EBP had a dressing change performed by an LPN who did not wear a gown or perform hand hygiene between glove changes. Furthermore, staff failed to disinfect a full body mechanical lift between uses with different residents, despite facility policy and DON expectations that lifts be sanitized between each resident. Staff interviews confirmed that lifts were only cleaned at the end of the day, not between residents.