Improper Infection Control During G-Tube Medication Administration
Penalty
Summary
A deficiency occurred when a nurse failed to follow infection prevention and control practices during medication administration for Resident 33, who received medications via a gastrostomy tube. During a medication pass observation, the nurse entered the resident’s room, donned a gown and gloves, and placed the resident’s prepared medication cups on the room’s heating unit. The nurse then used both gloved hands to pick up a fall mat from the floor beside the bed and lean it against the wall, and subsequently placed the cups of prepared medications on top of the upright fall mat. The nurse proceeded to administer the medications through the resident’s gastrostomy tube while also holding the end of the tube feeding administration tubing, which connects directly to the gastrostomy tube, in her left gloved hand. In an immediate interview, the nurse acknowledged that she had touched the fall mat on the floor with her gloved hands and then continued with medication administration without changing gloves or performing hand hygiene. In a later interview, the Nursing Home Administrator and the DON confirmed that the nurse should have removed her gloves, cleansed her hands, and applied clean gloves prior to administering the medications through the gastrostomy tube.
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