Failure to Follow Infection Control Protocols During Medication Administration and Isolation Precautions
Penalty
Summary
Facility staff failed to adhere to established infection prevention and control protocols during medication administration and when caring for residents on isolation precautions. Specifically, a medication aide did not perform hand hygiene before, between, or after contact with two residents during the medication administration process. The aide handled multiple medication blister packs and administered medications to both residents without washing or sanitizing hands at any point, despite facility policy requiring hand hygiene before and after resident contact and medication administration. The aide acknowledged awareness of the hand hygiene requirements but stated she forgot to perform them. Both residents involved had severe cognitive impairment, were incontinent, and dependent on staff for most activities of daily living. Their medical histories included conditions such as stroke, dementia, diabetes, hypertension, and chronic kidney disease. Observations confirmed that the medication aide did not follow hand hygiene protocols as outlined in the facility's policies, which emphasize hand hygiene as the most important step in preventing infection spread. Additionally, the Assistant Director of Nursing and a Certified Nursing Assistant entered the rooms of two residents on droplet precautions for COVID-19 without donning the required personal protective equipment (PPE), including N95 respirators, gowns, and gloves. Both staff members acknowledged after the fact that they were aware of the PPE requirements but did not follow them during the incident. Facility policy and posted signage clearly indicated the need for full PPE when entering rooms of COVID-19 positive residents.