Failure to Follow Infection Control and Enhanced Barrier Precautions
Penalty
Summary
The facility failed to administer medications and implement Enhanced Barrier Precautions (EBP) in accordance with its own infection prevention and control policies. During a medication pass, a registered nurse was observed using her fingers to obtain medications from bottles and medication cards without performing hand hygiene, and placed an insulin pen on a resident's bed linens before and after administration. The nurse acknowledged that these actions were improper and could lead to cross-contamination. The Director of Nursing confirmed that these practices should not have occurred. Additionally, staff did not consistently implement EBP for residents requiring such precautions. One resident with a history of sepsis due to MRSA received IV medication from a nurse who did not wear a gown, despite EBP signage indicating this requirement. Another resident with open wounds and on EBP was provided incontinent care by an LPN who did not wear a gown, stating she did not see the sign. There was confusion among staff regarding when gowns were required, with conflicting statements from the Staff Development Coordinator and the Infection Preventionist, despite clear signage outlining the need for gowns and gloves during personal care for residents on EBP.