Failure to Follow Infection Control Practices During Resident Care
Penalty
Summary
The facility failed to adhere to standard infection prevention and control practices during several resident care activities. Specifically, a registered nurse prepared intravenous (IV) medication for a resident with a peripherally inserted central catheter (PICC) and multiple diagnoses, including cellulitis and quadriplegia. The nurse allowed IV tubing to touch the floor and did not replace it before administering the medication. Additionally, the nurse entered the resident's room, which was under Enhanced Barrier Precautions (EBP), wearing only gloves and not a gown, as required. In another instance, the same nurse prepared an insulin injection for a resident with diabetes and other chronic conditions, left the needle exposed, and entered the resident's room without activating the safety cap, holding the exposed needle while waiting to administer the medication. Further deficiencies were observed during wound care and therapy assessments. Two wound care nurses provided treatment to a resident with a stage 4 sacral pressure injury, wearing gloves but not gowns, despite EBP signage indicating the need for both. An occupational therapist assessed two residents for range of motion without performing hand hygiene before or between assessments and without wearing gloves. The facility's policies and posted signage required the use of appropriate personal protective equipment (PPE) and hand hygiene during these activities, but these protocols were not followed as observed.