Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

Nurse #2 failed to follow the facility's infection control policies by not donning a gown while administering medications via a gastrointestinal tube to Resident #37, who was on Enhanced Barrier Precautions (EBP) due to the presence of a G-tube. The facility's EBP signage and infection control policies required all healthcare personnel to wear gloves and a gown for high-contact resident care activities, including feeding tube care. During the observed medication administration, Nurse #2 entered the resident's room, donned gloves, and proceeded with the G-tube medication administration without wearing a gown, despite clear signage and available personal protective equipment at the door. Nurse #2, an agency nurse on her second shift at the facility, acknowledged awareness of the EBP requirements but stated she forgot to wear the gown. The Staff Development Coordinator/Infection Preventionist confirmed that agency staff receive infection control education, including EBP, either prior to or upon arrival at the facility, and provided documentation of Nurse #2's orientation and training. The Administrator and SDC/IP both confirmed that the facility's process and policies require staff to wear gowns and gloves for G-tube care, and that infection control education is routinely provided through meetings and huddles.