Failure to Follow Infection Control Standards During Medication Administration and Resident Feeding
Penalty
Summary
Staff failed to follow infection control standards during medication administration and resident feeding, as observed and confirmed through interviews and record reviews. In one instance, a nurse was unable to remove a safety seal from a new liquid medication and used a writing pen to puncture and scrape the inside edge of the bottle opening. The nurse later acknowledged that this was inappropriate and could cause an infection control issue. The facility's policy on standard precautions requires measures to reduce the risk of infection transmission, but this was not followed in this case. In another event, a nurse brought a medication in its manufacturer’s box into a resident’s room and placed it directly on the bedside table without a barrier. After administering the medication, the nurse returned the medication to the box and placed it back in the medication cart with other boxed medications. The nurse confirmed that the medication box is porous and cannot be thoroughly cleaned, identifying this as an infection control issue. Facility leadership, including the Assistant Director of Nursing and Director of Nursing, confirmed that these actions were not in line with infection control expectations. Additionally, a certified nursing assistant was observed assisting two residents with eating in the dining room and touching potentially contaminated surfaces such as wheelchair handles, chairs, other residents’ trays, and countertops without performing hand hygiene between these actions. The assistant admitted to not considering the need for hand sanitizing after touching these surfaces. Facility policy requires hand hygiene after touching patient surroundings and before feeding, but this was not adhered to during the observed meal service.