Failure to Perform Hand Hygiene During Medication Pass
Penalty
Summary
The facility failed to administer medications in a manner that prevented cross-contamination for seven of thirteen residents observed during a medication pass. An LPN was observed repeatedly preparing and administering medications to multiple residents without performing hand hygiene between residents. The LPN handled the medication cart, medication cards, water cups, and touched door handles and other surfaces both inside and outside the building, as well as objects in the residents' environments, without cleaning her hands between each interaction. In one instance, the LPN only performed hand hygiene before administering eye drops, which she considered a treatment, but not between other medication administrations. The LPN acknowledged touching surfaces and objects that could contribute to cross-contamination and confirmed that she did not perform hand hygiene between residents unless a treatment was involved. During interviews, the Assistant Director of Nursing stated that staff were expected to perform hand hygiene before starting the medication pass and between each resident, and that handwashing should be repeated if hands became soiled. However, the facility did not have a specific handwashing policy, relying instead on a skills check for staff. Documentation showed that the LPN had been assessed as competent in handwashing, with instructions to perform hand hygiene between each resident's medication pass. Despite this, the observed practice did not align with these expectations, resulting in a failure to prevent potential cross-contamination during medication administration.