INDIANA, PA - Federal inspectors found that a Pennsylvania nursing home failed to maintain proper infection control protocols when a nurse administered medication that had been handled with bare hands after being dropped.
Communities at Indian Haven, located at 1675 Saltsburg Avenue, received citations following a February 5, 2025 inspection that revealed violations of infection prevention and control standards. The facility was cited for failing to ensure proper infection control practices during medication administration.
Medication Handling Violation Observed
During the inspection, federal surveyors observed a Licensed Practical Nurse administering medications to residents at 8:00 a.m. The nurse was observed dropping a 5 mg tablet of amlodipine, a blood pressure medication, onto the medication cart. Instead of discarding the medication and obtaining a replacement, the nurse picked up the dropped tablet with her bare hands and administered it to the resident.
When questioned immediately following the incident, the nurse acknowledged that she should not have touched the medication with her bare hands before giving it to the resident. The Nursing Home Administrator confirmed during a subsequent interview that facility policy prohibited staff from touching residents' medications with bare hands.
Infection Control Standards in Healthcare Settings
Proper medication handling protocols are fundamental to preventing healthcare-associated infections in long-term care facilities. When medications are dropped on surfaces and then handled with bare hands, they can become contaminated with bacteria, viruses, and other pathogens that may be present on hands or environmental surfaces.
Healthcare workers' hands can harbor numerous microorganisms, even when they appear clean. These pathogens can be transferred to medications and subsequently to residents' mouths during oral administration, potentially causing infections or compromising residents' health.
Standard Medication Administration Protocols
According to established healthcare protocols, dropped medications should be discarded and replaced with a fresh dose from the original container. If direct handling of medications is necessary, healthcare workers must use clean gloves or other barrier methods to prevent contamination.
The medication administration process requires adherence to the "five rights" of medication safety: right patient, right medication, right dose, right route, and right time. Proper infection control measures are considered an essential component of safe medication administration practices.
Impact on Vulnerable Populations
Nursing home residents represent a particularly vulnerable population due to age-related immune system changes and underlying health conditions. Many residents take multiple medications and may have compromised immune systems, making them more susceptible to infections from contaminated substances.
Blood pressure medications like amlodipine are commonly prescribed in long-term care settings, and residents depend on receiving these medications safely and without contamination. Proper handling procedures help ensure that therapeutic benefits are not compromised by preventable infections.
Regulatory Oversight and Compliance
The violation was identified under federal regulation F880, which requires nursing homes to provide and implement comprehensive infection prevention and control programs. These programs must include policies and procedures for safe medication handling and administration.
Pennsylvania nursing homes must also comply with state regulations under 28 Pa. Code 211.12, which governs nursing services and requires facilities to maintain appropriate standards for medication administration and infection control.
Facility Response Requirements
Communities at Indian Haven must develop and submit a plan of correction addressing how it will prevent similar violations in the future. This typically includes staff retraining on proper medication handling procedures, policy reviews, and enhanced monitoring of medication administration practices.
The facility received a "minimal harm" rating for this violation, indicating that while no actual harm occurred to residents, the potential for harm existed due to the improper infection control practices.
Federal and state regulators will continue to monitor the facility's compliance with infection control standards during future inspections to ensure that proper medication handling procedures are consistently followed by all staff members.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Communities At Indian Haven, from 2025-02-05 including all violations, facility responses, and corrective action plans.
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