Infection Control and Medication Administration Deficiencies
Penalty
Summary
Staff failed to follow proper infection prevention and control protocols during resident care and medication administration. During incontinent care for a resident with multiple comorbidities, including diabetes mellitus, ulcerative colitis, and morbid obesity, a CNA did not perform hand hygiene after removing soiled gloves and before donning new gloves. The CNA also failed to perform hand hygiene after removing gloves a second time and exiting the resident's room to provide a shower. These actions were observed and confirmed by an LPN, and were not in accordance with the facility's hand hygiene policy, which requires handwashing before and after direct resident contact and after glove removal. Medication administration practices were also found to be deficient. An LPN was observed removing multiple medications from pill cards with bare hands and physically touching each pill before administering them to three different residents. Additionally, the same LPN failed to clean a multi-resident blood glucometer between uses on different residents, despite being aware that the glucometer should be sanitized after each use. These practices were confirmed through staff interviews and were not consistent with infection control standards. Environmental sanitation issues were identified in the medication storage areas. The medication cart on one unit, which served 26 residents, was found to contain loose and broken tablets, as well as a significant accumulation of pill fragments and debris under the medication cards. Staff interviews confirmed that cleaning tasks were assigned but not consistently completed, and the Director of Nursing acknowledged that medication carts should be routinely cleaned and free of loose medications. Facility policies required proper storage and sanitation of medications, which was not maintained.