Failure to Perform Hand Hygiene During Medication Administration and Incontinence Care
Penalty
Summary
Staff failed to perform proper hand hygiene during medication administration and incontinence care, as observed and documented in the facility. An LPN administered oral medications to multiple residents consecutively without performing hand hygiene between residents. Specifically, after administering medications to one resident, the LPN did not sanitize or wash hands before preparing and administering medications to the next resident, only stopping when prompted by an observer. The LPN confirmed during an interview that hand hygiene was not performed between these tasks. In a separate incident, a CNA provided incontinence care to a resident with multiple medical conditions, including bowel and bladder incontinence, without removing soiled gloves or performing hand hygiene after cleaning the resident. The CNA then assisted the resident with additional tasks, such as donning clothing and preparing for transfer, while still wearing the same soiled gloves. The CNA acknowledged during an interview that gloves should have been removed and hand hygiene performed after completing the incontinence care. The facility's hand hygiene policy, based on CDC guidelines, requires staff to perform handwashing or use alcohol-based hand rubs at specific times, including before and after resident contact, after glove removal, and after contact with potentially contaminated surfaces. The observed failures to follow these procedures directly contravened the facility's established infection prevention and control protocols.