Failure to Follow Hand Hygiene and Glove Use During Medication Administration
Penalty
Summary
A deficiency was identified when a Medication Administration Technician (Med Tech) failed to follow infection control practices during medication administration to a resident with multiple complex medical conditions, including end stage renal disease, diabetes, cirrhosis, and dementia. The resident was under Enhanced Barrier Precautions (EBP) for wounds, which required all staff to perform hand hygiene before entering and after leaving the room, and to wear gloves and gowns during high-touch care activities. During observation, the Med Tech entered the resident's room without performing hand hygiene and did not wear gloves. The Med Tech administered an oral liquid medication, holding the cup to the resident's mouth with bare hands, and used a tissue to dab the resident's mouth when medication dribbled out, again without gloves. After administering the medication, the Med Tech discarded the used tissue and medication cup in the trash, touching the trash can lid, and attempted to use the wall-mounted alcohol hand rub dispenser in the resident's room, which was found to be empty. The Med Tech then left the room and used a dispenser in another resident's room. Interviews with the Med Tech, a Registered Nurse, and the Director of Nursing confirmed that the expected protocol was not followed, as hand hygiene should have been performed before entering the room and gloves should have been worn due to the potential contact with bodily fluids.