Failure to Implement Enhanced Barrier Precautions and Proper Medication Administration
Penalty
Summary
The facility failed to implement and maintain proper infection control practices for residents requiring Enhanced Barrier Precautions (EBP) and during medication administration. Multiple residents with conditions such as neuromuscular dysfunction of the bladder, indwelling catheters, chronic wounds, and feeding tubes were identified as needing EBP according to their care plans. However, observations revealed that there was no signage indicating EBP requirements on their room doors, nor was personal protective equipment (PPE) available for staff to use during close contact care. These lapses were confirmed by the Director of Nursing and a Registered Nurse, both certified Infection Control Practitioners, who acknowledged that EBP had not been implemented as required and that physician orders or care plans had not been reviewed during their audit. Additionally, during medication administration, a registered nurse was observed preparing medications when a pill fell onto the medication cart. The nurse retrieved the pill using the medication card and placed it into a medication cup with other medications before administering them to a resident. This practice did not adhere to proper infection control protocols for medication administration, as the pill was potentially contaminated before being given to the resident.