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F0880
D

Improper Syringe Use Breaches Infection Control Protocol

Gettysburg, Pennsylvania Survey Completed on 08-14-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

A deficiency occurred when a registered nurse used a single-dose syringe to administer medication to two different residents, which is a breach of infection prevention and control practices. The incident involved a resident who was asleep when the nurse placed a syringe in her mouth, containing medication intended for her spouse, who was on hospice care. The resident immediately objected, but reported tasting some of the medication before the syringe was removed. The nurse then used the same syringe to administer morphine to the resident's spouse. This action was reported by the resident to nursing staff later that morning and to her daughter in the evening. The resident was being treated for bacterial sinusitis with antibiotics at the time of the incident. The facility's infection control policy, consistent with CDC guidelines, requires that single-dose syringes never be used for more than one patient. The administrator confirmed that the syringe should have been discarded after its initial use and acknowledged that the event should have been reported by the nurse involved. The nurse in question is no longer employed at the facility.

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