Failure to Follow Hand Hygiene Protocols During Medication Administration
Penalty
Summary
A deficiency was identified when a Licensed Practical Nurse (LPN) failed to follow proper hand hygiene protocols during medication administration for three residents. The facility's hand hygiene policy required staff to sanitize their hands before preparing or handling medications and after removing gloves. However, during a medication pass, the LPN prepared and administered medications to one resident, then donned gloves and took another resident's blood pressure without sanitizing her hands. After removing her gloves, she again failed to sanitize her hands before preparing and administering medications to the next resident. This pattern continued as the LPN checked a third resident's blood sugar, removed gloves, and prepared medications without hand sanitizing, only using hand sanitizer at the medication cart after completing the rounds. Interviews with the LPN and the Director of Nursing confirmed that the LPN did not adhere to the required hand hygiene procedures during the medication pass and after glove removal. The observations and staff interviews demonstrated a failure to implement the facility's infection prevention and control policies, specifically regarding hand hygiene during direct resident care activities.
Plan Of Correction
Resident 45 was assessed with no ill effects and/or noted concerns related to License Practical Nurse 1 failing to use proper hand washing techniques during her medication administration. Resident 29 was assessed with no ill effects and/or noted concerns related to License Practical Nurse 1 failing to use proper hand washing techniques during her medication administration. Resident 2 was assessed with no ill effects and/or noted concerns related to License Practical Nurse 1 failing to use proper hand washing techniques during her medication administration. The Director of Nursing immediately spoke to Licensed Practical Nurse 1 regarding proper hand sanitization during medication administration, including after glove removal, with Licensed Practical Nurse 1 verbalizing understanding and willingness to comply. Current facility residents receiving medications have the ability to be affected by this alleged deficient practice. A baseline audit was completed on residents currently receiving medications to ensure licensed nurses completed hand washing/hand hygiene during medication administration, including after glove removal. Hand washing/hand hygiene competencies were completed with current facility licensed staff and current agency licensed staff. Direct care staff, including agency direct care staff, were re-educated on the facility's Hand Hygiene Policy, including the importance of proper hand sanitization during medication administration and after glove removal. Facility direct care staff, including agency direct care staff, received training regarding appropriate practices for wearing gloves, changing gloves, hand washing, and hand hygiene, including when to wear and change gloves, perform hand washing and/or hand hygiene during resident care and treatment. Facility licensed staff, including agency licensed staff, were re-educated on preventing the spread of infection, including hand washing/hand hygiene. The Director of Nursing/designee will audit licensed nurses administering medications to residents weekly times four weeks then monthly times three months to ensure proper hand washing/hand hygiene utilized throughout medication administration. Results from audits will be reviewed by the Quality Assurance Performance Improvement Committee for recommendations and/or resolution at its regularly scheduled meetings times four months for results, areas of improvement, and/or continuation of audits.