Infection Control Lapses During Resident Care and Medication Administration
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by multiple observed lapses in infection control practices involving three residents. During a medication pass, a medication aide did not sanitize a blood pressure cuff between use on two different residents. The aide acknowledged forgetting to sanitize the cuff, which is necessary to prevent cross contamination between residents. In another instance, a licensed vocational nurse administered medication via a PEG tube to a resident who was on enhanced barrier precautions due to the presence of a feeding tube and a urinary catheter. The nurse wore gloves but did not don a PPE gown as required by the resident's care plan and physician orders for enhanced barrier precautions. Facility policy and CMS guidance require the use of gowns and gloves during high-contact care activities for residents with indwelling medical devices. Additionally, two certified nursing assistants provided incontinent care to a resident with a history of dementia, enterocolitis due to C. difficile, and chronic kidney disease. The CNAs did not perform hand hygiene between glove changes during the care process, despite removing and replacing gloves multiple times. Both CNAs stated they were not trained to sanitize their hands between glove changes, although facility policy and the nursing supervisor indicated that hand hygiene should be performed at these times.