Infection Control Lapses in Medication Administration, Wound Care, and Environmental Hygiene
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by multiple observed lapses in staff adherence to established protocols. During a medication pass for a resident with quadriplegia and a PEG tube, an LPN administered medications and flushed the tube without wearing a gown, despite the facility's Enhanced Barrier Precautions (EBP) policy requiring both gown and gloves for such procedures. The LPN acknowledged forgetting to don a gown, and the Director of Nursing confirmed this was not in compliance with policy. The resident's medical record indicated ongoing PEG tube care for administration of Baclofen and Gabapentin. Further deficiencies were observed during wound care, where a treatment nurse failed to perform hand hygiene before preparing and applying wound dressings. The nurse handled clean gauze with ungloved hands, placed it into a cup, and then sprayed it with wound cleanser, contaminating the supplies. The nurse admitted to not performing hand hygiene and using the contaminated gauze on the resident's wound, which was inconsistent with the facility's standard precautions policy. Additional observations revealed improper storage of resident care items, with unused supplies such as adult briefs, wash basins, and under-pads stored directly on the floor, and used basins and a soiled urinal left on the shower floor. A shower curtain was also found to be visibly soiled, with staff unable to state the cleaning frequency or protocol. Facility administration confirmed these storage and cleanliness issues were not in accordance with expected standards.