Failure to Follow Hand Hygiene Protocols During Medication Administration
Penalty
Summary
The facility failed to ensure proper infection prevention and control measures were followed during medication administration for three residents. Facility policy required hand hygiene before direct contact with residents, before applying gloves, and after removing gloves. However, observations revealed that staff did not consistently perform hand hygiene at the required times. Specifically, one LPN did not perform hand hygiene between glove changes while administering eye drops to a resident. Another RN failed to perform hand hygiene before and after administering medications and removing gloves. A third LPN did not perform hand hygiene before preparing medications, before and after glove changes, and after administering medications, including eye drops and an inhaler. Interviews with the Director of Nursing confirmed that staff were expected to perform hand hygiene as outlined in facility policy, including before preparing medications and between glove changes. The observed lapses in hand hygiene occurred during direct care and medication administration to residents, as documented by surveyors during their review and interviews.