Failure to Follow Infection Control Practices During Medication Administration
Penalty
Summary
The deficiency involves a failure to follow the facility’s infection prevention and control practices during medication administration, contrary to the facility’s Medication Administration policy that requires staff to remove medications from storage without directly touching them. Resident #60, admitted with diagnoses including COPD and diabetes, had physician orders for fifteen morning medications, including Colace 100 mg by mouth. During a medication pass observed on 3/4/26 at 8:30 AM, RN #3 placed all fifteen medications into a medication cup and brought them into the resident’s room. When Resident #60 stated she did not want the Colace, RN #3 removed the Colace capsule from the medication cup using her ungloved finger before handing the remaining medications to the resident. During an interview at 8:37 AM the same day, RN #3 acknowledged she should have used a spoon or donned gloves to remove the Colace from the medication cup and had not done so. Later that afternoon, the CNO confirmed that RN #3 should not have used her ungloved finger to remove the medication from the cup. These observations and interviews demonstrated that the facility failed to maintain infection control practices as required by its own policy during medication administration for Resident #60.
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