Failure to Follow Hand Hygiene and Infection Control During Medication Pass
Penalty
Summary
A Qualified Medication Aid (QMA) failed to follow infection control practices during medication administration to five residents across multiple hallways. The QMA was observed popping medication tablets out of bubble packs directly into the palm of her hand, placing them into medication cups, and administering them to residents without performing hand hygiene before, during, or after the medication pass. This practice was repeated with several residents, including after performing tasks such as blood pressure checks and handling residents' clothing, and continued as the QMA moved from one resident to another without sanitizing her hands. The QMA also documented medication administration and immediately began preparing medications for the next resident without washing or sanitizing her hands. Observations included the QMA handling medications and interacting with residents in their rooms and in common areas, such as the hallway and therapy gym, without following hand hygiene protocols. The facility's Unit Manager confirmed that staff are expected to sanitize their hands between each resident during medication passes and that medications should not be dispensed by being popped into a staff member's hand. Hand sanitizer was available on the medication cart, but was not used by the QMA during the observed period. Facility policies provided by the Administrator required hand hygiene before and after medication administration and the use of standard precautions for all residents, regardless of infection status. Enhanced Barrier Precautions and Contact Precautions signage was posted on several residents' doors, instructing staff to clean their hands before entering and after leaving rooms. Despite these policies and posted instructions, the QMA did not adhere to required hand hygiene practices during the observed medication passes.