Failure to Follow Enhanced Barrier Precautions and Hand Hygiene During Medication Administration
Penalty
Summary
Facility staff failed to follow appropriate infection prevention and control practices during medication administration for a resident with a gastrostomy tube (G-tube). During observation, a registered nurse (RN) did not wear a protective gown while administering medications via the G-tube, despite a clearly posted sign indicating the need for enhanced barrier precautions (EBP) for high-contact activities such as device care or use, including feeding tubes. The RN was observed entering the resident's room wearing only a surgical mask and gloves, and she stated she was unsure if a gown was required, mistakenly believing the EBP applied to the resident's roommate. Throughout the medication administration process, the RN did not change gloves or perform hand hygiene between different care activities and after touching various surfaces both inside and outside the resident's room. The RN was seen preparing and administering multiple medications, including eye drops and inhalation medication, without changing gloves or washing hands between procedures. Excess liquid from the G-tube was wiped from the resident's abdomen with a tissue, and the RN continued to access the tube and administer medications without changing gloves. The RN also left and re-entered the room multiple times, handling items such as spoons and cups of water, without removing gloves or performing hand hygiene. The facility's policies and procedures require the use of gowns and gloves for high-contact activities involving indwelling medical devices, such as feeding tubes, and mandate hand hygiene before and after medication administration and between procedures. The RN acknowledged during interviews that she did not change gloves or perform hand hygiene as required, and the Director of Nursing confirmed that staff are expected to follow these protocols. The failure to adhere to established infection control practices was directly observed and confirmed through staff interviews and policy review.