Failure to Perform Hand Hygiene and Initiate Isolation Precautions
Penalty
Summary
Staff failed to perform proper hand hygiene during medication administration for two residents. An LPN administered multiple oral medications to one resident, including opening capsules with bare hands and mixing them with applesauce, without performing hand hygiene before or after the process. The same LPN then administered medications to a second resident, again failing to perform hand hygiene after the medication pass. These actions were observed and later confirmed in an interview with the LPN, and were not in accordance with the facility's policy, which requires handwashing before and after medication administration and after direct resident contact. Additionally, the facility failed to implement isolation precautions for a resident who was readmitted with a diagnosis of influenza A. The resident exhibited symptoms such as a moist cough and abnormal lung sounds and was receiving antiviral medication. Despite these symptoms and a confirmed diagnosis, there was no documentation in the medical record or physician orders indicating that isolation precautions were initiated for this resident. The facility's policies on medication administration and transmission-based precautions were reviewed and found to require hand hygiene and the initiation of isolation precautions for residents with transmissible infections. The Director of Nursing confirmed that isolation precautions were not implemented for the resident with influenza A, and the observed medication administration practices did not follow the facility's established guidelines.