Failure to Maintain Infection Control During Medication Administration
Penalty
Summary
Surveyors observed that nursing staff failed to maintain proper infection prevention practices during medication administration for six residents. Specifically, two nurses were seen placing medications and medical devices, such as glucometers and insulin pens, on unclean surfaces without disinfecting them before or after use. Shared equipment, including blood pressure cuffs and pulse oximeters, was not cleaned between residents, and personal protective equipment (PPE) was not appropriately donned or doffed between resident care activities. In several instances, hand hygiene was not performed after glove removal, and items were returned to the medication cart without proper disinfection or adherence to required contact times for germicidal wipes. The residents involved had significant medical conditions, including diabetes, heart failure, and asthma, which required frequent monitoring and medication administration. During medication passes, nurses were observed placing glucometers and insulin pens on bare surfaces of medication carts and bedside tables, both in common areas and resident rooms. In multiple cases, nurses failed to sanitize equipment between uses and did not follow hand hygiene protocols after removing gloves or before handling medications and devices for different residents. These actions were confirmed by staff interviews, where nurses acknowledged not following established infection control protocols due to being rushed or distracted by other duties. Facility policies and CDC guidelines reviewed by surveyors clearly required cleaning and disinfecting shared equipment before and after each use, performing hand hygiene according to established procedures, and using PPE appropriately. The Director of Nursing confirmed that staff were expected to adhere to these protocols. However, direct observations and staff admissions demonstrated that these standards were not consistently followed during the observed medication administration processes.