Improper Handling of Prefilled Morphine Syringes Breaches Infection Control
Penalty
Summary
The deficiency involves a failure to maintain an infection prevention and control program when handling a resident’s prefilled morphine syringes. The resident was an elderly female with diabetes mellitus, hypertension, and a history of cerebral infarction, with a BIMS score of 8/15 indicating severely impaired cognition, requiring extensive to total assistance with ADLs, and on hospice care with a terminal prognosis related to CVA. Her care plan included close observation for pain and administration of pain medication as ordered, and her orders included PRN oral morphine sulfate concentrate. During observation of the medication cart, an LVN was counting the resident’s prefilled morphine syringes when one syringe fell to the floor. The LVN picked up the fallen syringe and placed it back with the other nine syringes instead of wiping or destroying it, thereby contaminating the remaining syringes. In interview, the LVN acknowledged the syringe that fell became contaminated and that she should have wasted it with another nurse. The DON stated the syringe that fell should have been wasted and that placing it back with the others contaminated all of them, identifying this as an infection control issue. The facility’s medication administration policy required staff to follow established infection control procedures, and when the infection control policy was requested from the administrator, it was not provided upon exit.
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