EL CAJON, CA - Federal inspectors documented infection control violations at San Diego Post-acute Center where licensed nurses repeatedly failed to follow proper hand hygiene protocols during medication administration.
Hand Hygiene Failures During Medication Administration
The February 27, 2025 inspection revealed that Licensed Nurse 12 consistently failed to perform hand hygiene after removing gloves while administering medications to residents. Federal surveyors observed the nurse during medication rounds for two residents, documenting multiple instances where proper infection control procedures were not followed.
During one observed medication pass with a resident who had a gastrostomy tube (g-tube), the nurse removed gloves without washing hands, then put on new gloves multiple times throughout the procedure without performing hand hygiene between glove changes. The resident, who had functional quadriplegia and required tube feeding, was particularly vulnerable to infections due to the medical devices and compromised health status.
The observation revealed concerning practices including the nurse picking up an alcohol swab from the floor, filling medication cups with water from a bathroom sink while wearing contaminated gloves, and handling multiple surfaces including privacy curtains and tissue boxes during the medication administration process.
G-tube Administration Complications
The inspection documented a particularly problematic situation when the nurse encountered a clogged feeding tube. The nurse removed and replaced gloves multiple times while attempting to clear the obstruction, using various interventions including "milking" the tube with ointment and employing a declogger device. Throughout this extended procedure involving multiple equipment changes and manipulations, proper hand hygiene was not consistently performed between tasks.
When interviewed, Licensed Nurse 12 acknowledged being "not consistent in performing hand hygiene during the med pass" and stated understanding the importance of hand hygiene for infection control.
Second Instance of Protocol Violations
Federal inspectors also documented hand hygiene failures with another licensed nurse during medication administration to a resident with epilepsy and encephalopathy. Licensed Nurse 21 was observed preparing and administering medications without performing hand hygiene prior to entering the resident's room, though hand hygiene was performed after completing the medication administration.
When questioned about the observed practice, Licensed Nurse 21 acknowledged failing to perform hand hygiene before administering medications and confirmed understanding that hand hygiene prevents infection transmission.
Medical Significance of Hand Hygiene Violations
Hand hygiene represents the most fundamental infection prevention measure in healthcare settings. The failure to perform proper hand hygiene during medication administration creates significant risks for healthcare-associated infections, particularly concerning for nursing home residents who often have compromised immune systems and multiple chronic conditions.
G-tube administration requires especially stringent infection control measures since the feeding tube provides a direct pathway into the digestive system. Contaminated hands or equipment can introduce bacteria directly into the stomach, potentially causing serious gastrointestinal infections or systemic infections that can be life-threatening for vulnerable residents.
Residents with neurological conditions like functional quadriplegia, epilepsy, and encephalopathy face elevated infection risks due to potential swallowing difficulties, reduced mobility, and compromised physiological responses to infections. These individuals depend entirely on healthcare staff following proper infection prevention protocols.
Facility Policy Requirements
The facility's own medication administration policy, revised in April 2019, specifically requires staff to follow established infection control procedures including handwashing when administering medications. The policy emphasizes that medications must be administered "in a safe manner" with proper infection control protocols.
Nursing supervisors confirmed during interviews that the expectation was for all licensed nurses to perform hand hygiene between tasks and prior to medication administration to prevent resident infections. The Acting Director of Nursing and Assistant Director of Nursing both acknowledged these established expectations during the survey.
Kitchen Equipment Safety Issues
The inspection also identified equipment safety violations in the dietary department where the dishwashing sink drain pipe was emptying water directly onto the kitchen floor instead of into the designated drain. This created slip hazards for dietary staff and potential flooding risks.
The Dietary Manager manually adjusted the pipe during the inspection and acknowledged that proper drainage was essential for staff safety. Facility policy requires floors to be kept "clean, dry, and free of obstructions" and specifies that equipment discharging liquid waste should drain through proper channels.
Industry Standards for Infection Prevention
Healthcare facilities are required to maintain comprehensive infection prevention and control programs under federal regulations. Hand hygiene compliance represents a basic quality indicator that reflects broader infection control practices within a facility.
Proper hand hygiene protocol requires washing hands or using alcohol-based hand sanitizer before and after each resident contact, before and after medication administration, after removing gloves, and after contact with potentially contaminated surfaces. The World Health Organization identifies five key moments for hand hygiene in healthcare settings, with medication preparation and administration representing critical intervention points.
Facility Response and Oversight
During the inspection, facility administrators stated they were unaware of the infection control issues and indicated that their Quality Assurance committee should have identified these trends before they were discovered by federal surveyors. The Acting Director of Nursing confirmed the importance of identifying and addressing infection control concerns to maintain the highest quality of life for facility residents.
The violations were classified as having minimal harm or potential for actual harm, affecting few residents. However, infection control failures can rapidly escalate into facility-wide outbreaks if not promptly addressed through staff retraining, policy reinforcement, and enhanced monitoring systems.
Federal regulations require nursing facilities to establish and maintain infection prevention programs that include staff training, policy development, outbreak prevention, and continuous monitoring of compliance with established protocols.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for San Diego Post-acute Center from 2025-02-27 including all violations, facility responses, and corrective action plans.
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