Infection Control Lapses in Medication Administration, Catheter Care, and Resident Hand Hygiene
Penalty
Summary
Surveyors observed multiple failures in infection prevention and control practices among staff. A certified medication aide (CMA) administered medication to a resident using an inhaler and returned the uncleaned inhaler to its box in the medication cart, despite acknowledging that the mouthpiece should have been cleaned with an alcohol pad after use. The inhaler was stored with other residents' medications, increasing the risk of cross-contamination. Additionally, a certified nurse aide (CNA) was observed cleaning urine from the floor and then, without changing gloves or performing hand hygiene, adjusted a resident's urinary catheter bag valve before resuming cleaning. The CNA admitted uncertainty about when to change gloves and perform hand hygiene, and agreed that his actions increased the resident's risk of infection. Another CNA assisted a resident after bathroom use but did not remind or assist the resident to perform hand hygiene, even though the resident was capable of independently washing his hands but did not always remember to do so. The CNA acknowledged the importance of resident hand hygiene after bathroom use. The facility's policies on metered-dose inhaler administration and hand hygiene were reviewed and found to require cleaning and hand hygiene in the situations observed, but there were no facility policies for glove use or resident hand hygiene.