Failure to Follow Infection Control and Medication Handling Policies
Penalty
Summary
The deficiency involves failure to implement infection prevention and control policies, including Enhanced Barrier Precautions and medication administration protocols. Resident 92 had a stage 4 pressure ulcer of the right buttock and dementia, with physician orders for enhanced barrier infection precautions and a care plan identifying risk for MDRO colonization/infection due to chronic wounds. The care plan required use of gown and gloves for high-contact activities, including wound care. During an observed dressing change to Resident 92’s sacral pressure ulcer, a registered nurse completed the ordered wound care without wearing a gown at any time, contrary to the resident’s care plan and the facility’s Enhanced Barrier Precautions policy. The Nursing Home Administrator later stated she would expect employees to use appropriate personal protective equipment. Additional deficiencies were identified related to infection control and medication handling on the South Wing C Hall medication cart and during medication administration. An LPN stored a personal jacket in the bottom drawer of the medication cart along with medications and acknowledged that the jacket should not be in the cart; the DON confirmed staff personal items should not be stored in medication carts. In a separate observation of medication administration for another resident, the same LPN placed the resident’s inhaler and antibiotic eye drops, in their boxes, directly on the overbed table without a clean barrier, did not apply gloves before administering antibiotic eye drops, and did not wear gloves when applying a lidocaine patch. After administration, the LPN returned the inhaler and eye drop boxes to the medication cart drawer. The LPN acknowledged she should have used a clean barrier and worn gloves, and the DON confirmed that gloves and a clean barrier were required by facility policy.
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