Failure to Maintain Enhanced Barrier Precautions and Infection Control During Resident Care and Medication Administration
Penalty
Summary
Certified Nursing Assistants (CNAs) failed to follow enhanced barrier precautions (EBP) during the care of a resident with a cholecystostomy tube. The resident, who had multiple diagnoses including acute cholecystitis, acute renal failure, diabetes, and required assistance with personal care, was on EBP due to the presence of an indwelling device. Despite clear signage and the availability of personal protective equipment (PPE) outside the room, two CNAs transferred the resident using a Hoyer lift without wearing gloves or gowns. Both CNAs acknowledged during observation that they should have been wearing PPE, and the Director of Nursing (DON) confirmed this requirement based on the resident's EBP status. Additionally, an LPN failed to maintain infection control practices during medication administration for another resident. The LPN did not perform hand hygiene before administering medications and handled pills directly with her hands before placing them into a medication cup. This was observed and confirmed by the surveyor, and the LPN admitted to being new. The DON confirmed that medications should not be handled directly by hand and should be placed into the cup or on the lid. Facility policy requires staff to follow infection control procedures, including handwashing and proper technique, during medication administration.