Failure to Use Gloves During Medication Administration
Penalty
Summary
A deficiency occurred when a licensed vocational nurse (LVN) failed to use gloves while opening Depakote Sprinkles capsules for a resident during medication administration. The resident involved was an elderly female with severe dementia, essential hypertension, and cognitive communication deficits, who required supervision with eating and drinking. The resident's care plan included interventions for medication administration and monitoring for signs and symptoms of dysphagia. Despite facility policy and accepted infection control standards requiring glove use to prevent cross contamination, the LVN did not wear gloves when opening the capsules. Multiple staff interviews, including those with a medication aide, the LVN involved, the registered charge nurse (RCN), the director of nursing (DON), and the administrator (ADM), confirmed that the expected practice was to wear gloves during this procedure. The facility's infection control policy also specified glove use to reduce the risk of transmitting microorganisms. The failure to follow these procedures was observed directly and acknowledged by staff as a breach of infection control practices, potentially exposing the resident to cross contamination.