F0880

D

Failure to Follow Hand Hygiene Protocol During Medication and Glucose Management

Bennington, Vermont Survey Completed on 03-11-2026

Penalty

Fine: $12,735

Summary

Surveyors identified a deficiency in the facility’s infection prevention and control program related to hand hygiene during medication administration for two of nine sampled residents. During an observation of medication administration, an LPN had nine missed opportunities to perform required hand hygiene, failing to use hand sanitizer or soap and water before and after glove use while preparing and administering oral medications to Resident #1. The same LPN also did not cleanse hands before and after glove use when preparing eye drops and glucose testing for Resident #89, instilling eye drops, testing blood glucose with a glucometer, cleaning the glucometer, disposing of used testing supplies, preparing an insulin injection, administering the insulin injection, and upon completion of the injection. In an interview, the LPN acknowledged that hand hygiene should be performed before and after putting on gloves, direct resident contact, preparing or handling medications, visiting a resident’s room, and after handling contaminated equipment such as a glucometer. The facility’s Hand Hygiene Policy states that gloves do not replace hand hygiene and that an alcohol-based hand sanitizer with at least 62% alcohol must be used before preparing or handling medications, before and after direct resident contact, and after glove removal.

These observations, interviews, and record reviews demonstrated that the facility did not ensure staff adherence to its own hand hygiene policy and infection control standards during medication preparation and administration and during the use and cleaning of a glucometer for Resident #1 and Resident #89.