Failure to Follow Hand Hygiene and Glucometer Disinfection Practices During Med Pass
Penalty
Summary
The deficiency involves failure to follow infection prevention and control standards during medication administration on the west wing, involving four residents over a 42‑minute observation period. An LPN with long artificial nails was observed repeatedly handling oral medications with bare hands, including inserting a finger into multi‑dose bottles and using a fingernail to scoop pills out, then placing the pills into a medication cup. On multiple occasions, pills were removed from pharmacy blister cards into the palm of the LPN’s bare hand before being transferred to a medication cup, and a pill that fell onto the top of the medication cart was picked up with a bare hand and placed into the cup. These practices occurred despite facility policies requiring good hand hygiene prior to handling medications and maintaining fingernails short, neat, and trimmed. During blood glucose monitoring and medication administration for one resident, the LPN donned gloves to perform a fingerstick and used a glucometer, but after completing the procedure, disposed of the lancet, medication cup, and gloves, placed the glucometer on top of the medication cart, and began documenting on the computer without performing any hand hygiene. The glucometer was later placed into the medication cart drawer without any cleaning or disinfection. The LPN then proceeded to administer medications to additional residents, again handling medications in the bare hand and entering and exiting resident rooms without performing hand hygiene between residents or before returning to the medication cart and computer. Throughout the observation period, the LPN moved between multiple residents, the medication cart, the nurses’ station, and the treatment cart without performing hand hygiene, despite direct contact with resident environments and equipment. After administering medications and preparing a dose of MiraLAX for another resident, the LPN again failed to perform hand hygiene before accessing the treatment cart drawers and manipulating wound care supplies, which were then taken into a resident’s room. When questioned, the LPN acknowledged the importance of hand hygiene to prevent spreading germs between residents and stated that sanitizer was normally kept in a pocket but was in a bag at that time. Facility policies reviewed by surveyors specified that staff must perform hand hygiene before beginning a medication pass, prior to handling any medication, after direct resident contact, and before and after invasive procedures such as fingerstick blood sampling, as well as maintain appropriate fingernail hygiene.
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