Failure to Follow Infection Control Practices During Medication Administration and Enhanced Barrier Precautions
Penalty
Summary
The facility failed to maintain proper infection control practices during medication administration and while implementing Enhanced Barrier Precautions (EBP). In one instance, a registered nurse (RN) was observed performing a blood glucose check for a male resident with type 2 diabetes without using a barrier between the glucometer and the surfaces it was placed on, such as a stool and countertop. The RN also transported insulin pens in his shirt pocket before and after administration, contrary to facility policy. Interviews with staff revealed a lack of consistent understanding and adherence to the requirement for using barriers during blood sugar checks and proper handling of insulin pens, despite facility policy and expectations set by the Director of Nursing (DON). In another instance, a resident with severe cognitive impairment, quadriplegia, and a feeding tube was observed receiving direct care from an RN who wore only gloves, omitting other required personal protective equipment (PPE) such as a gown or mask, despite an EBP sign on the resident's door and a physician's order for enhanced barriers during high-contact care. The RN did not acknowledge or demonstrate awareness of the EBP requirements during the procedure. These actions resulted in failures to follow established infection prevention and control protocols for both shared equipment and resident care.