Failure to Perform Hand Hygiene During Medication Administration
Penalty
Summary
The deficiency involves the facility’s failure to maintain an infection prevention and control program during medication administration for one resident. A medication aide (MA A) administered medications to Resident #1 without performing hand hygiene before retrieving medications from the medication cards. During the observed med pass, MA A placed her bare hand into a multi-dose bottle of buspirone 15 mg tablets, touching multiple pills inside the container, and then proceeded with medication administration. After completing the medication administration for Resident #1, MA A again failed to wash her hands or perform hand hygiene. Resident #1 was an elderly female with acute respiratory failure, Alzheimer’s disease, metabolic encephalopathy, restlessness, and agitation, and had severe cognitive impairment with a BIMS score of 2. She required substantial/maximal assistance with most ADLs and was receiving multiple oral medications, including cyanocobalamin, folic acid, memantine, buspirone, divalproex sodium, losartan, and a multivitamin with minerals. The facility’s hand-washing policy stated that hand hygiene is the primary means to prevent the spread of healthcare-associated infections and specified that hand hygiene is indicated immediately before touching a resident and after touching a resident or their environment. Despite having received infection control training during orientation and being able to describe cross contamination as not washing hands before providing care, MA A did not follow the facility’s hand hygiene policy during the observed medication administration.
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