Failure to Implement Enhanced Barrier Precautions and Safe Medication Handling
Penalty
Summary
The deficiency involves failures in the facility’s infection prevention and control practices related to both enhanced barrier precautions (EBP) and medication handling. One resident, R96, was observed lying in bed with family at the bedside with no EBP signage posted and no EBP setup outside the room, despite having a Jackson-Pratt (JP) drain to the right groin for a right groin hematoma and an order to empty and monitor the drain every shift. On two separate observations, there was no EBP order, no signage, and no setup in place, even though the facility’s EBP policy requires use of gowns and gloves and posting of EBP signs for residents with indwelling medical devices, regardless of colonization status. The Infection Preventionist acknowledged that R96 should have had an EBP order due to the surgical drainage. A second deficiency was identified during a medication pass observation involving R89. An LPN prepared a 100 mg dose of magnesium oxide when only a 400 mg house stock tablet was available. The LPN cut the 400 mg tablet into four parts, handled the medication pieces with bare hands, and returned the remaining three-quarters of the tablet to the original stock bottle without performing hand hygiene at any point. The DON later stated that medications should not be touched with bare hands and that once a tablet is split, any unused portion should be discarded rather than returned to the original container for infection control purposes. The facility did not have a specific written policy on handling medications, but the stated standard practice was that medications should not be handled with bare hands for infection control reasons.
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