Repeat Infection Control Failures During Medication Administration
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program related to medication administration practices and staff personal items on medication carts. During a medication pass observation, an RN donned gloves and poured medications into individual 30 cc cups, accessed the nurse’s station refrigerator twice to obtain pudding for crushed medications, and continued preparing medications without removing gloves or performing hand hygiene. The RN then crushed pills, mixed them with pudding, and carried the cups with his gloved fingers inside the medication cups to administer the medications to Resident #41, without removing gloves or performing hand hygiene before or during this process. These actions were inconsistent with the facility’s Handwashing/Hand Hygiene Policy, which requires handwashing before and after resident contact, including during medication administration. In a separate observation, surveyors noted a large cup with a lid and straw on a medication cart during medication administration. When questioned, the nurse acknowledged the drink was hers and stated she believed it was acceptable because it had a lid. In an interview, the DON confirmed that failing to perform proper hand hygiene before or during medication preparation and placing fingers, gloved or ungloved, inside medication cups increases the risk of contamination, and also confirmed that staff drinks are not allowed on medication carts because of infection control concerns, regardless of whether the cup has a lid. The report notes this is a repeat deficiency, with similar violations cited during the previous three re-certification surveys.
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