Unsanitary Practice During Medication Administration
Penalty
Summary
During medication administration, a Licensed Practical Nurse (LPN) was observed using the tip of a pen, retrieved from a stack of papers on the medication cart, to open single-dose blister pods containing oral medications for three residents. The pen, which had not been sanitized and was left unattended on the cart, was used to create a U-shaped opening in the blister pods, allowing the tablets to be removed and placed into medication cups. This practice was observed during the administration of medications such as Carvedilol and Protonix for a resident with chronic cardiopulmonary and gastrointestinal conditions, and Sinemet for two residents with Parkinson's disease and related diagnoses. The LPN confirmed that the pen was used for this purpose and acknowledged that it had never been sanitized. Interviews with the LPN and the Director of Nursing confirmed the use of the unsanitized pen to open medication packaging, which was not in accordance with the facility's medication administration policy. The policy required medications to be administered as prescribed, following manufacturers' specifications and good nursing practices, and specified that staff should avoid touching medications unless wearing gloves. The observed practice affected three residents out of twelve observed during medication administration, with the facility census at 29.