Failure to Perform Hand Hygiene During Medication Administration
Penalty
Summary
The facility failed to maintain proper infection control practices during medication administration for three residents. Qualified Medication Aide (QMA) 2 was observed preparing and administering medications without performing hand hygiene at critical points, such as before donning and after doffing gloves, and prior to administering medications. During medication preparation, QMA 2 touched various surfaces and objects, including scissors, storage bags, medication drawers, and a computer mouse, without performing hand hygiene before proceeding to handle medications or interact with residents. For one resident with vascular dementia, QMA 2 prepared and crushed medications, mixed them with pudding, and administered them without hand hygiene before glove use or medication administration. For another resident with hypertension, QMA 2 prepared medications, donned gloves, administered eye drops, and touched the resident's face without hand hygiene before leaving the medication cart or donning gloves. In a third case involving a resident with vascular dementia, QMA 2 prepared oral medications and a medication patch, touched multiple surfaces, and applied the patch without hand hygiene prior to administration. Interviews with QMA 2 and the Infection Preventionist confirmed that hand hygiene should have been performed at these points, and the facility's policy also required hand hygiene before medication pass and before leaving the medication cart.