Failure to Follow Infection Control Practices During Medication Administration
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program during the preparation and administration of medications to four residents. Facility policy directed staff to avoid touching medications unless wearing gloves, but observations revealed that a staff member, after cleansing her hands and donning gloves, touched unclean surfaces such as medication cart keys and drawer handles before handling oral medications. She then pushed pills from blister packs into her gloved hands and placed them into medicine cups, subsequently administering these medications to three residents without changing gloves or performing hand hygiene between tasks. The staff member confirmed during interview that she had touched the medications with the same gloves that had contacted unclean items. Additionally, another staff member was observed preparing an insulin injection for a resident using an insulin pen. The staff member applied a new needle to the pen without cleansing the rubber seal, contrary to manufacturer instructions. The facility's policy on subcutaneous insulin did not include guidance to cleanse the rubber seal before needle application, and the staff member confirmed she had not performed this step. The DON acknowledged that both staff members did not follow appropriate infection control practices as required by facility policy and manufacturer guidelines.