Failure to Perform Hand Hygiene and Proper Medication Administration
Penalty
Summary
A deficiency was identified when a Licensed Practical Nurse (LPN) failed to perform hand hygiene after removing gloves and before handling the medication cart computer mouse. The LPN discarded gloves in the trash and immediately began typing on the computer without sanitizing hands, contrary to the facility's Handwashing/Hand Hygiene policy, which requires hand hygiene after glove removal and as the final step after removing personal protective equipment. When questioned, the LPN indicated that hand hygiene would be performed after completing charting and also stated being an agency nurse. Additionally, during medication administration, the same LPN retrieved a new insulin pen for a resident and accessed the pen with a needle without first cleaning the pen's rubber septum. When asked about the requirement to clean the pen hub, the LPN stated that it was unnecessary for a new pen. The Unit Manager later confirmed that staff are expected to sanitize hands after glove removal and clean the insulin pen's hub before use, regardless of whether the pen is new. These actions were observed during medication administration for one resident and were inconsistent with facility policy, creating the potential for cross-contamination.