Failure to Perform Required Hand Hygiene During Medication Administration
Penalty
Summary
A deficiency occurred when an LPN failed to follow the facility’s infection prevention and control practices for hand hygiene during medication administration. On 12/16/25 at 9:48 AM, the LPN administered medications to resident R59 and did not perform hand hygiene afterward. Immediately following this, the LPN responded to resident R83’s call light, attended to the resident’s needs, turned off the call light, and handled items on the resident’s tray table, including a food plate cover and a cloth table napkin, which he then carried to the nursing station and handed to another staff member. The LPN then resumed the medication pass and prepared medications for resident R81 before finally using hand sanitizer, acknowledging when informed of the observation that he should have performed hand hygiene after administering medications to R59 and before preparing medications for R81. The ADON later confirmed that the LPN should have performed hand hygiene before and after medication administrations, consistent with the facility’s Medication Pass Guidelines policy, which requires hand hygiene before starting the med pass and specifies proper technique for soap-and-water and alcohol-based hand rub use. This deficiency affected two residents (R59 and R81) reviewed for infection control during medication administration, as the LPN’s sequence of actions involved direct resident care and handling of potentially contaminated items between medication administration tasks without appropriate hand hygiene, contrary to the facility’s written policy.
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