Failure to Perform Hand Hygiene During Medication Administration
Penalty
Summary
A deficiency was identified when a licensed vocational nurse (LVN) failed to perform hand hygiene during medication administration for two residents. The LVN was observed handing medications and water to one resident, then documenting the administration without performing hand hygiene after handling the medications and after the medication pass. In a separate instance, the same LVN prepared medications for another resident without performing hand hygiene before or after handling the medications. The two residents involved had significant medical histories. One resident had end stage renal disease, was dependent on renal dialysis, and had Type 2 diabetes mellitus, requiring supervision or assistance with several activities of daily living. The other resident had Type 2 diabetes mellitus, acute osteomyelitis of the left ankle and foot, and cellulitis of the left lower limb, requiring substantial or maximal assistance with personal care tasks. Interviews with the Infection Preventionist Nurse and the Director of Nursing confirmed that facility policy and standard infection control practices require hand hygiene before and after medication administration and resident contact. Review of the facility's hand hygiene policy further supported these requirements, stating that hand hygiene is the primary means to prevent the spread of infections and must be performed before and after direct contact with residents and before preparing and handling medications.
Plan Of Correction
F880: Infection Prevention and Control Corrective Action: On 04/17/25, Resident 27 and Resident 62 were assessed by a licensed nurse. Both residents did not show any adverse reaction or signs of infection caused by the deficient practice. LVN 4 is no longer working in the facility. In-service initiated on 04/17/2025 by DON regarding infection control with an emphasis on hand hygiene during medication pass and also before and after care with residents. Other Resident Affected Identification: All residents have the potential to be affected by the deficient practice. On 04/17/25, DON/Designee conducted a random observation of 4 licensed nurses during medication pass. All licensed nurses observed performed hand hygiene appropriately. No other residents were affected by the deficient practice. On 05/02/2025, IP nurse/Designee initiated a weekly random medpass observation to 2 random licensed nurses to ensure proper hand hygiene is performed. PERFORMANCE MONITORING: DON/designee will report any findings/trends during monthly QAA meeting for review x90 days or until substantial compliance has been achieved.