Failure to Follow Hand Hygiene Protocol During Medication Administration
Penalty
Summary
A deficiency was identified when a Licensed Practical Nurse (LPN) failed to follow proper infection control practices during medication administration for a resident with a percutaneous gastrostomy (PEG) tube. After administering medications via the PEG tube, the LPN immediately proceeded to administer eye drops to the same resident without removing gloves or performing hand hygiene, as observed by surveyors. The facility's hand hygiene policy requires staff to perform hand hygiene before moving from a contaminated body site to a clean body site during resident care, and specifically after contact with blood or bodily fluids. The resident involved had a history of cerebral infarction with dysphagia, hemiplegia, and hypertension, and was dependent on staff for most activities of daily living. Physician orders for this resident included enteral flushes before and after medication administration via the PEG tube and the use of eye drops. The Director of Nursing confirmed during an interview that the LPN should have removed gloves and performed hand hygiene before administering the eye drops, in accordance with facility policy.