Failure to Use Required PPE During Central Line Medication Administration
Penalty
Summary
A deficiency occurred when a nurse failed to follow the facility's infection prevention and control program during the administration of IV medication to a resident with a central line. The resident, who had diabetes with a foot ulcer and an unhealed pressure injury, was on enhanced barrier precautions (EBP) due to the presence of a central line and risk of infection. The resident's care plan and posted instructions outside the room specified that gloves and a gown were required for high-contact activities, including central line care. During an observed medication administration, the nurse sanitized her hands, donned gloves, and administered the IV medication but did not wear a gown as required by EBP protocols. When questioned, the nurse expressed uncertainty about the need for a gown during IV medication administration and indicated she was unaware of other staff using gowns for similar procedures. The Director of Nursing and the Administrator both confirmed that the expectation was for staff to use appropriate PPE, including gowns, when caring for residents on EBP with central lines. Facility policy also required the use of gloves and gowns for high-contact activities involving indwelling medical devices. The failure to adhere to these protocols was identified through observation, interview, and record review.