Failure to Prevent Cross Contamination During Medication Administration
Penalty
Summary
A deficiency occurred when a nurse failed to follow proper infection prevention and control procedures during medication administration. During a medication pass, an LPN was observed retrieving a stock bottle of aspirin, dispensing a tablet into the lid, and accidentally dropping a tablet onto the medication cart. The LPN then picked up the dropped tablet from the cart surface and placed it back into the stock bottle with the other tablets, instead of discarding it. This action was witnessed during direct observation and later confirmed by the LPN in an interview, where she acknowledged that the tablet should have been thrown away. The affected resident had a history of chronic obstructive pulmonary disease, epilepsy, and nontraumatic intracerebral hemorrhage, and required assistance with activities of daily living. The facility's policy on medication administration required staff to follow established infection control procedures, which were not adhered to in this instance. The Director of Nursing confirmed that nurses are not permitted to touch medications with bare hands, further verifying the breach in protocol.