Medication Error Rate Exceeds Acceptable Threshold Due to Lapses in Hand Hygiene and Equipment Disinfection
Penalty
Summary
Staff failed to maintain a medication error rate below 5%, with 3 medication errors observed out of 29 opportunities, resulting in a 10.34% error rate. During medication administration, a Certified Medication Aide (CMA) did not clean the blood pressure cuff and vital sign equipment before taking a resident's vitals, did not sanitize her hands before beginning a medication pass for another resident, and failed to don gloves before opening a capsule for a third resident. These actions were directly observed during the survey. The CMA confirmed during interview that she should have sanitized her hands before the medication pass, cleaned the vital sign equipment before and between each resident, and worn gloves before handling medications. The Director of Nursing also confirmed that staff are expected to follow these procedures. Review of facility policy and CDC guidelines further supported the requirement for hand hygiene and equipment disinfection before and after resident contact and medication administration.