Failure to Perform Hand Hygiene During Medication Administration
Penalty
Summary
Staff failed to perform proper hand hygiene during medication administration for two residents. In one instance, an LPN entered a resident's room, used a blood pressure cuff, and administered oral medications without performing hand hygiene before or after the procedure. The LPN also handled equipment and medication cups without cleaning hands between tasks or after leaving the resident's room. The LPN confirmed during an interview that hand hygiene was not performed as required. In another case, a different LPN prepared oral medications, entered a resident's room without performing hand hygiene, and handed the medication cup to the resident. When the resident dropped a pill on her shirt, the LPN picked up the pill with bare hands and placed it back into the medication cup, rather than using gloves and discarding the pill. The LPN acknowledged not following proper hand hygiene or glove use. Facility policy and interviews with the DON and unit manager confirmed that staff are expected to perform hand hygiene before and after medication administration and to use gloves and discard dropped pills, but these procedures were not followed.