Failure to Follow Enhanced Barrier Precautions During G-Tube Medication Administration
Penalty
Summary
The facility failed to maintain an infection prevention and control program in accordance with accepted national standards for a resident who required enhanced barrier precautions due to the presence of a gastrostomy tube (g-tube). During a medication administration observation, a licensed vocational nurse (LVN) did not wear a gown while administering medications via the g-tube, despite facility policy and CDC guidelines requiring gown and glove use for high-contact care activities involving residents with indwelling medical devices. The resident involved was a female with multiple diagnoses, including Huntington's Disease, dysphagia, aphasia, and Alzheimer's disease, and was dependent on staff for all care and received nutrition exclusively through a feeding tube. Interviews with the LVN, the Infection Preventionist, the Director of Nursing (DON), and the Administrator confirmed that staff were expected to wear gowns and gloves during g-tube medication administration for residents on enhanced barrier precautions. The facility's infection control policy and CDC guidelines both specified the need for such precautions for residents with indwelling medical devices. The failure to follow these protocols was observed and acknowledged by staff, with the potential for infection risk noted in their statements.