Failure to Perform Hand Hygiene During Medication Administration
Penalty
Summary
Surveyors identified a deficiency in infection prevention and control related to medication administration when an LPN failed to perform required hand hygiene. Resident #29, admitted on 10/27/22 with a diagnosis of type 2 diabetes mellitus and documented as having intact cognition on a quarterly MDS assessment, was observed receiving eight medications prepared and administered by LPN #215 without the LPN washing her hands or using hand sanitizer beforehand. During the observation on 1/28/26 at 8:29 A.M., the LPN placed all medications into a medicine cup and administered them to the resident without performing hand hygiene. In a subsequent interview at 8:47 A.M. the same day, LPN #215 confirmed she did not perform hand hygiene before administering the medications and stated she forgot and did not have hand sanitizer on her cart. In an interview on 1/29/26 at 7:00 A.M., the DON confirmed that facility practice requires hand hygiene to be performed before and after administering medications to each resident. Review of the facility’s undated Medication Administration policy showed it directs staff to perform appropriate hand hygiene before beginning medication administration and before and after each resident’s medications are administered. Review of the undated Standard Precautions policy indicated that practicing hand hygiene is an effective way to prevent the spread of infections and specifies when to perform hand hygiene for care between residents.
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