Failure to Follow Infection Control and Medication Handling Protocols
Penalty
Summary
Facility staff failed to adhere to infection prevention and control standards during wound care for two residents. For one resident with a pressure ulcer requiring dressing changes, both a CNA and a nurse assisted with toileting and wound care while wearing gloves but did not don gowns, as required by the facility's Enhanced Barrier Precautions (EBP) policy. The resident's room also lacked EBP identification. For another resident with an indwelling urinary catheter and heel ulcers, two nurses performed wound dressing changes while wearing gloves but did not use gowns, despite EBP signage and supplies being present at the room entrance. Administrative staff confirmed that gowns were expected to be worn during these high-contact care activities. Additionally, during a medication pass for the resident with an indwelling catheter and heel ulcers, a nurse dropped a Vitamin B complex capsule onto the medication cart, picked it up with a bare hand, and placed it into the medication cup for administration. Facility policy requires that any medication whose integrity or sanitation is compromised, such as being touched by hand after being dropped, must be destroyed. An administrative nurse confirmed that the expected practice was to discard such compromised medication.