Infection Control Failures During Medication Administration and Handling of Soiled Linens
Penalty
Summary
The deficiency involves failures in infection prevention and control during medication administration and handling of feces-soiled linens. For one resident with schizoaffective disorder, visual loss, mood disorder, psychosis, prediabetes, toxic effect of carbon monoxide, cocaine dependence, major depressive disorder, homelessness, adult failure to thrive, and post-traumatic stress disorder, an agency LPN was observed during a morning medication pass popping an Amlodipine 5 mg tablet directly from the medication card into her bare hand before placing it into a medication cup. When stopped and interviewed by the surveyor, the LPN confirmed she had touched the tablet with her bare hands and intended to administer it to the resident. In a separate observation, another resident with chronic kidney disease, atrial fibrillation, heart failure, depression, and cerebral infarction was receiving medications when an LPN poured an Aspirin 81 mg tablet from a bottle into her bare hand and then popped Carvedilol 25 mg and Eliquis 5 mg tablets from medication cards into her bare hand before placing all tablets into a medication cup. This LPN also verified during interview that she had handled the tablets with bare hands and planned to administer them. The deficiency also includes improper handling of feces-soiled linens for a resident admitted with chronic obstructive pulmonary disease, a solitary pulmonary nodule, anxiety disease, and respiratory failure. During the initial tour, the resident’s room door was open and a CNA was brushing the resident’s hair while a hand towel and a blue disposable pad, both heavily soiled with feces, were lying directly on the floor. During interview at that time, the CNA acknowledged that feces-soiled items should not have been placed directly on the floor without a barrier or in a plastic bag. Review of the facility’s Laundry Services policy dated 02/2022 stated that soiled linens should be handled as little as possible, with minimal agitation, and that all soiled linen would be bagged or placed in carts at the location where the resident was cared for, with linens saturated in blood or body fluids placed in a biohazard bag.
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