Failure to Perform Hand Hygiene During Medication Administration
Penalty
Summary
The deficiency involves a failure by LVN A to follow hand hygiene practices during medication administration to two residents, in violation of the facility’s infection prevention and control program. Video evidence from the evening medication pass showed LVN A entering the shared room of Resident #1 and Resident #2 holding two small clear medication cups in her bare, ungloved hands. LVN A placed both cups on Resident #1’s bedside table and, without washing her hands, using alcohol-based hand sanitizer (ABHS), or donning gloves, proceeded to administer Resident #1’s medications, including handling and maneuvering Resident #1’s beverage straw with bare hands before handing the resident the medication cup. The same video evidence showed that after administering medications to Resident #1, LVN A picked up the second medication cup from Resident #1’s bedside table and went to Resident #2’s bedside. Without performing hand hygiene or donning gloves, LVN A administered Resident #2’s medications from the same type of clear plastic administration cup and then left the room without washing her hands or using ABHS. Record review confirmed that Resident #1, an older female with peripheral vascular disease, secondary drug-induced Parkinsonism, emphysema, and moderate cognitive impairment, had orders for Atorvastatin and Gabapentin at bedtime, and that these were documented as administered by LVN A. Resident #2, an older female with pneumonia, dementia with severe cognitive impairment, and epilepsy, had a bedtime Atorvastatin order that was also documented as administered by LVN A. Staffing records confirmed LVN A was working the relevant shift when these medication administrations occurred.
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