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F0880
D

Failure to Implement Infection Control During Medication Administration

Medford, Massachusetts Survey Completed on 08-01-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

Nursing staff failed to adhere to the facility's infection prevention and control program during medication administration. Specifically, a nurse was observed picking up keys to lock the medication cart and then placing two fingers inside a plastic cup of water to carry it into a resident's room. The nurse entered resident rooms on multiple occasions to administer medications without performing hand hygiene, and was also seen touching a bathroom door handle without subsequent hand hygiene. Additionally, the nurse removed a lidocaine patch from a resident's shoulder without wearing gloves and did not perform hand hygiene after the task. During interviews, the nurse acknowledged not following proper hand hygiene protocols, including not performing hand hygiene before entering resident rooms, placing fingers inside a water cup, and failing to wear gloves when removing a lidocaine patch. The DON confirmed that staff are expected to perform hand hygiene before entering resident rooms, wear gloves when coming into contact with residents, and perform hand hygiene before and after glove use. These observations and staff admissions demonstrate a failure to implement the facility's infection prevention and control policies as required.

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