Failure to Follow Hand Hygiene Protocols During Medication Pass
Penalty
Summary
The facility failed to ensure proper infection control practices were followed during medication administration, specifically regarding hand hygiene. Observations revealed that one LPN did not perform hand hygiene after leaving one resident's room before preparing medication for another resident, nor before donning gloves to enter the next resident's room. The same LPN also failed to perform hand hygiene at multiple points during another medication pass, including after checking a resident's blood pressure, before preparing medication, and prior to applying a pain patch. Another LPN was observed not performing hand hygiene before entering a resident's room to administer medication after retrieving a medication from the medication room. Interviews with the staff indicated a lack of awareness regarding the need for hand hygiene at specific points during the medication pass process. The facility's current hand hygiene policy requires hand hygiene before and after direct contact with a resident's skin and after glove removal. The observed failures to follow these procedures were confirmed by both direct observation and staff interviews.