Failure to Follow Infection Control Practices During Wound Care and Medication Administration
Penalty
Summary
The facility failed to implement effective infection prevention and control practices for three residents, as evidenced by direct observations and staff interviews. For one resident with multiple diagnoses including multiple sclerosis and Alzheimer's disease, who was severely cognitively impaired and had pressure ulcers, the Director of Nursing (DON) did not perform hand hygiene before donning gloves and providing wound care. The resident had physician orders for wound treatment but no order for enhanced barrier precautions (EBP), despite facility policy and CMS guidance indicating EBP should be used for residents with wounds. The DON confirmed the lack of hand hygiene and acknowledged the need for EBP for this resident. Additionally, during medication administration, an LPN was observed preparing and administering medications to two residents consecutively without performing hand hygiene between residents. Both residents were at risk for infection according to their care plans. The LPN confirmed she did not wash her hands or use hand sanitizer between medication passes. Facility policy required hand hygiene immediately before touching a resident, but this was not followed during the observed medication administration.