Failure to Perform Proper Hand Hygiene During Medication Administration and Resident Care
Penalty
Summary
Staff failed to follow proper hand hygiene protocols during medication administration and resident care, as observed with two LPNs. One LPN entered a resident's room without performing hand hygiene, repositioned a roommate, checked oximetry, and administered medications without sanitizing hands between tasks or before preparing medications for the next resident. The LPN acknowledged during an interview that hand hygiene should have been performed between residents and prior to medication preparation but did not do so. Another LPN also prepared medications and entered a resident's room without performing hand hygiene, later admitting to forgetting the procedure due to nervousness. Further observation revealed that an LPN did not perform hand hygiene before conducting a blood glucose check or before donning gloves, only washing hands after removing gloves. The LPN stated that hand hygiene was unnecessary because gloves were worn. Interviews with the Infection Control nurse and the DON confirmed that staff are expected to perform hand hygiene before and after resident care, and that glove use does not replace handwashing. Facility policies reviewed also required hand hygiene at key points during care and medication administration.