Improper Handling of Oral Medications During Med Pass
Penalty
Summary
Surveyors observed that during a morning med pass, LPN BB removed multiple blister-pack medications from the cart and repeatedly popped six pills from six separate blister packs into her bare hand before transferring them into a medication cup, without performing hand hygiene between handling the pills. LPN BB also removed floor stock medication from the cart and poured those pills from the bottle into her hand before placing them into the same medication cup. Another nurse, LPN CC, was present near the medication cart, witnessed the interaction, and verbally told LPN BB that pills should never be popped into the hand because it was an infection control issue. In a subsequent interview, LPN BB confirmed she had popped the pills into her hand, stated that this was how she had been trained, and reported she was a new graduate and new nurse, licensed in November 2025, working PRN with only one day of orientation before passing medications. The DON later stated that her expectation was for nursing staff to pop pills directly into a cup and not into their hands. The deficient practice identified was the failure to follow infection control practices during medication administration for one of three residents observed, specifically by handling oral medications in a manner inconsistent with the facility’s stated expectations for infection prevention and control.
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