Failure to Prevent Cross-Contamination During Medication Administration
Penalty
Summary
Facility staff failed to administer medications in a manner that prevents the transmission of communicable diseases and infections. During medication administration, staff were observed dispensing oral medications directly into their bare hands before placing them into medication cups for residents. This practice was observed with two residents, both of whom had intact cognition and complex medical histories, including conditions such as pulmonary embolism, heart failure, hypertension, diabetes, and hyperlipidemia. For one resident, an LPN dispensed multiple medications, including allopurinol, apixaban, gabapentin, sacubitril-valsartan, vitamin D, empagliflozin, and metoprolol, directly into her hand from blister cards before transferring them to a medication cup. The LPN acknowledged during the observation that this was not the correct procedure and that the medications were considered contaminated as a result. The contaminated medications were discarded, and the process was restarted. In a separate incident, an RN dispensed atorvastatin directly into his bare hand before placing it in a medication cup for another resident. The RN also recognized this as improper practice and discarded the medication. Interviews with the Assistant Director of Nursing (ADON), who also served as the Infection Preventionist, the Director of Nursing (DON), and the Administrator confirmed that the facility's expectation was for medications to be dispensed directly from the medication card into a medication cup, not into staff hands, to avoid cross-contamination. Facility policy on infection control was reviewed, but the medication administration policy did not specify procedures for oral medication administration. All interviewed staff agreed that dispensing medications into bare hands constituted an infection control issue.