Failure to Perform Hand Hygiene Prior to Medication Preparation
Penalty
Summary
A deficiency occurred when a Licensed Vocational Nurse (LVN) prepared to administer Gabapentin to a resident without first performing hand hygiene, as required by the facility's infection prevention and control protocol. The LVN entered the resident's room, prepared the medication by unscrewing two Gabapentin capsules to mix with applesauce, but did not wash hands or use alcohol-based hand sanitizer prior to handling the medication. The LVN acknowledged during an interview that handwashing had only occurred earlier, downstairs, and that he had touched doorknobs while using the stairs to return to the resident's room before preparing the medication. The resident involved had diagnoses including dementia, neuralgia, and neuritis, with functional limitations in the lower extremities and limited ability to make concrete requests, though able to comprehend most conversation. The facility's policy, reviewed and dated July 2024, specifies that all personnel must perform hand hygiene before preparing or handling medications. The Director of Nursing confirmed that handwashing is required before medication preparation and handling, and failure to do so could result in the spread of infection.