Failure to Perform Hand Hygiene During Medication Administration
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program by not ensuring proper hand hygiene during medication administration for three residents. Observations revealed that an LPN repeatedly neglected to perform hand hygiene at critical points, such as before and after entering resident rooms, before handling medications, and after direct resident contact. The LPN was seen unlocking the medication cart, preparing medications, and assisting residents with repositioning and medication administration without using hand sanitizer or washing hands. In one instance, the LPN donned gloves without prior hand hygiene, performed a blood glucose check, and then administered oral medication without removing gloves or sanitizing hands, potentially exposing residents to contaminants. Interviews with the LPN confirmed a lack of adherence to hand hygiene protocols, with the staff member acknowledging the failure to use hand sanitizer or wash hands at appropriate times. The Director of Nursing stated that staff are expected to follow infection control policies, which require hand hygiene before and after medication administration and after glove removal. Policy reviews further supported that the facility's procedures mandate hand hygiene at these points, but these were not followed during the observed medication passes.