Improper Handling of Oral Medications Without Hand Hygiene
Penalty
Summary
Surveyors observed that the facility failed to maintain infection control practices during medication administration when a qualified medication aide (QMA) handled oral medications with bare hands. On 1/23/26 at 9:44 a.m., QMA 5 was seen at the medication cart touching medication drawers and multiple medication cards, then removing a tablet from a medication card by popping it into her bare hand and placing it into a medication cup containing other medications, identified at that time as belonging to Resident 53. During this process, QMA 5 did not perform hand hygiene with soap and water or hand sanitizer before handling the medication or at any point during the observation. Resident 53’s clinical record, reviewed on 1/22/26, showed diagnoses including type II diabetes mellitus. In an interview, the DON stated that staff should not touch medication tablets with their bare hands, and the facility’s medication administration policy specified that medications are to be administered in a manner to prevent contamination or infection and that staff should remove medications from their source while taking care not to touch them with bare hands. These observed actions and the lack of hand hygiene were inconsistent with the facility’s written medication administration policy and professional standards of practice intended to prevent contamination or infection.
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