Failure to Follow Contact Isolation and Infection Control Procedures
Penalty
Summary
A deficiency occurred when a Licensed Vocational Nurse (LVN) failed to follow the facility's infection control policy for a resident who was on contact isolation precautions. The LVN entered the resident's room without wearing the required gown and gloves, despite a contact isolation sign being posted outside the room. The LVN also did not perform hand hygiene before or after entering the room. The resident had severe cognitive impairment and required significant assistance with daily activities, and the need for contact isolation was documented in the resident's records. During medication administration, the LVN prepared crushed medications mixed with applesauce for the resident. When the resident refused the medication, the LVN labeled the medicine cup and placed it inside the locked medication cart, specifically in a section next to a glucometer that is used for multiple residents. The facility's Director of Nursing confirmed that the safest practice would have been to discard the prepared medication to prevent confusion and potential cross-contamination, and acknowledged that placing the medicine cup next to a shared glucometer could contribute to the spread of infection. A review of the facility's policies confirmed that staff are required to wear gloves and gowns when entering rooms under contact precautions, and to perform hand hygiene before and after room entry. The infection control policy also emphasizes maintaining a safe and sanitary environment to prevent the transmission of disease and infections. The observed actions by the LVN did not align with these established procedures.