Failure to Follow Infection Control and Medication Administration Protocols
Penalty
Summary
The facility failed to implement proper infection prevention and control techniques on the second-floor nursing unit and during two observed medication administration passes. On one occasion, a nursing assistant provided care to a resident with a wound, who had Enhanced Barrier Precaution (EBP) signage posted on the door, without wearing any personal protective equipment (PPE) as required by facility policy. Additionally, there was no appropriate disposal container for PPE inside the resident's room. Interviews with staff revealed a lack of awareness regarding the reason for the EBP signage, and the infection preventionist confirmed that staff were not consistently using EBP gowns when providing care to the resident. The resident also reported that this was the first time a nursing aide had worn a PPE gown during care, indicating a pattern of non-compliance with EBP protocols. During medication administration, an LPN failed to complete one resident's medication pass before moving to another resident to take vital signs, and did not ensure the correct administration of eye drops as ordered by the physician. The LPN also did not perform hand hygiene after administering medication to one resident and before providing care to another, nor after taking vital signs and before handling medication again. These actions were in direct violation of the facility's infection control policies and standard precautions, as well as state regulations regarding nursing services.