Failure to Follow Hand Hygiene Protocol During Medication Administration
Penalty
Summary
Surveyors identified a deficiency in the facility's infection prevention and control practices during medication administration observations involving two Licensed Practical Nurses (LPNs). On multiple occasions, after administering medication and performing hand hygiene, the LPNs turned off the faucet with their bare hands instead of using a paper towel, as required by both facility policy and standard infection control protocols. In one instance, an LPN dried her hands with a paper towel, used the same damp towel to turn off the faucet, and then obtained additional towels to finish drying her hands. Interviews with the LPNs confirmed their awareness that the correct procedure was to use a paper towel to turn off the faucet after handwashing, but they failed to follow this protocol during the observed events. The facility's hand hygiene policy specifically instructs staff to use a disposable towel to turn off the faucet after washing and drying hands. The observed actions were inconsistent with this policy and with accepted infection control standards designed to prevent recontamination of hands after washing. Further interviews with facility staff demonstrated knowledge of the correct hand hygiene procedure, including the use of a clean paper towel to turn off the faucet. However, the observed lapses in practice by the LPNs during medication administration tasks resulted in a failure to maintain proper infection control practices, as required by federal and state regulations.
Plan Of Correction
F 880 Infection Prevention & Control CFR(s): 483.80(a)(1)(2)(4)(e)(f) 483.80 Infection Control 1. Address how corrective action will be accomplished for those residents found to have been affected by the deficient practice: Resident 112 was [R] Resident 226 was [R] Resident 41 was [R] 2. Address how the facility will identify other residents having the potential to be affected by the same deficient practice: All residents have the potential to be affected by this deficient practice. 3. Address what measures will be put into place or systemic changes made to ensure that the deficient practice will not recur: Director of Nursing or designee in-serviced all licensed nursing staff regarding handwashing during medication pass and assisting residents. 4. Indicate how the facility plans to monitor its performance to make sure that solutions are lasting: Director of Nursing or designee will conduct audits on three random staff members to ensure proper hand washing. These audits will be conducted weekly x 4 weeks, then every other week for 4 weeks, and then monthly x 3 months. The results of the audit will be reported to the facility QAPI committee until compliance is determined to be sustained. F 880