Failure to Follow Hand Hygiene Protocol During Medication Administration
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program as evidenced by the actions of an LVN during medication administration to a resident with a history of hypertension and cellulitis. The LVN was observed not performing hand hygiene before donning gloves, after removing gloves, or between handling medications and resident care items. Specifically, the LVN prepared and administered oral medications, including antibiotics and pain medication, without using hand sanitizer or washing hands at critical points, such as before entering the resident's room, after glove removal, and after exiting the room. The LVN also handled medication cups, pudding containers, and the resident's bed controls without appropriate hand hygiene. The resident involved had moderately impaired cognition and was being treated for cellulitis of the lower right leg, requiring antibiotics and pain management. The facility's own hand hygiene policy, which requires hand washing or use of alcohol-based hand rub before and after direct resident contact, before preparing or handling medications, after contact with objects in the resident's vicinity, and after glove removal, was not followed. Interviews with the LVN, DON, and Administrator confirmed the expectation for proper hand hygiene practices, which were not met during the observed medication administration.