F0880

D

Failure to Follow Infection Control Practices During Enteral Tube Medication Administration Under EBP

West Allis, Wisconsin Survey Completed on 01-14-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to maintain an effective infection prevention and control program during enteral tube (ET) medication administration for one resident on Enhanced Barrier Precautions (EBP). The resident had acute respiratory failure with hypoxia, a tracheostomy, a gastrostomy tube, an indwelling urinary catheter, was NPO with continuous tube feeding, and was dependent on staff for all ADLs. Facility policies required keeping the medication cart clean and using EBP, including gown and gloves for high-contact care involving devices such as feeding tubes, tracheostomies, and catheters, and disposing of PPE before exiting the room or before providing care to another resident.

During a medication pass, an LPN prepared and administered ET medications for this resident and did not consistently follow infection control practices. After initially performing hand hygiene and donning PPE, the LPN brought the resident’s graduated cylinder and syringe, prefilled with water and used for ET care, out of the resident’s room and placed the cylinder on the medication cart, leaving a puddle of fluid of unknown contamination on the cart. The LPN did not sanitize the cart and later placed medication cups and a stethoscope on the same contaminated surface. The LPN also repeatedly wiped the syringe, including the tip that connects directly to the resident’s ET, with a contaminated gloved hand after water or medication mixture dripped down the syringe during flushing and medication administration attempts.

While wearing PPE in the EBP room, the LPN exited the room without removing gown and gloves or performing hand hygiene and accessed a shared spoon container on the medication cart used for all residents, then returned to the room and continued care without changing PPE or performing hand hygiene. The LPN used the spoon to mix the medication and continued to manipulate the syringe and ET with the same contaminated gloves. The LPN later discarded the clogged syringe and medication mixture, obtained a new syringe and medication, and repeated similar practices of wiping the syringe, including the tip, with contaminated gloves after fluid overflow. Interviews with the LPN, the ADON (infection preventionist), and the DON confirmed that these actions were not consistent with facility expectations or standard practice, including that resident-specific items such as the graduated cylinder should not leave the room, PPE should be removed and hand hygiene performed before accessing the medication cart or exiting an EBP room, and the syringe tip that connects to the resident should not be wiped with a gloved hand.

The facility’s own leadership acknowledged that the observed practices did not align with their policies and expectations. The ADON stated that staff are expected to remove PPE before exiting an EBP room and before accessing anything outside the room, especially a shared medication cart, and that resident-specific care items like the graduated cylinder should not be placed on communal surfaces. The DON similarly stated that the graduated cylinder should remain in the resident’s room, medications should be prepared either at the bedside with that cylinder or at the cart with another water source, and that staff must remove gloves and perform hand hygiene before accessing the cart and then re-perform hand hygiene and don gloves before resuming care. Both the ADON and DON stated there is no standard of practice to wipe a syringe, particularly the tip that connects to the resident, with a contaminated gloved hand. These statements, combined with the surveyor’s observations, establish that the facility did not maintain its infection prevention and control program as required by its own policies and EBP standards during ET medication administration for this resident.

The surveyor’s interviews further documented that the LPN acknowledged that bringing the graduated cylinder out of the room and placing it on the cart was not standard practice and that the cylinder should not leave the room. The LPN also acknowledged that it is not standard practice to wipe off a syringe with a contaminated gloved hand prior to administering fluids or medications through an ET and that accessing items on the cart while wearing contaminated PPE is not consistent with infection control standards. Despite these acknowledgments, the observed actions during the medication pass demonstrated multiple breaches of infection control, including contamination of the medication cart, improper handling of resident-specific equipment, failure to remove PPE and perform hand hygiene before accessing shared supplies, and improper handling of the syringe tip used for ET access. These combined actions and inactions led to the cited deficiency in the facility’s infection prevention and control program.