Failure to Follow Infection Control Protocols During IV Medication Administration
Penalty
Summary
A deficiency was identified when a licensed vocational nurse (LVN) failed to follow infection prevention and control protocols while administering intravenous (IV) antibiotics to a resident. The resident had a history of osteomyelitis in the left foot and ankle, Type 2 diabetes, muscle weakness, and was on enhanced barrier precautions (EBP) due to wounds and a feeding tube. The care plan also indicated the resident required isolation for MRSA in a wound, with interventions specifying hand washing and the use of protective equipment. On the observed occasion, the LVN entered the resident's room wearing only a mask, without donning a gown or gloves, and did not sanitize or wash hands upon entry. The LVN proceeded to hang the IV medication, handled supplies, and used the overbed table without sanitizing it before or after the procedure. The LVN also failed to wash hands upon exiting the room. These actions were captured on video and confirmed through interviews with facility staff, who stated that proper protocol required hand hygiene, use of gown and gloves, and sanitizing surfaces before and after procedures involving IV medications. Facility policies reviewed included requirements for enhanced barrier precautions and infection control, but the intravenous therapy policy did not specifically address infection control guidelines. Staff interviews confirmed that the observed practices did not align with facility expectations or infection control standards, placing the resident at risk for infection and cross-contamination.