Improper Handwashing Technique Observed During Medication Administration
Penalty
Summary
The facility failed to ensure an environment free from the potential spread of infection on one of its nursing units. The deficiency was identified during a review of facility policies, observations, and staff interviews. The facility's handwashing policy, last reviewed without changes, requires staff to use a disposable towel to turn off the faucet as the last step of the handwashing technique. However, during a medication administration pass, an LPN was observed using the back of her arm to turn off the faucet after washing her hands, which is contrary to the facility's policy. The observations revealed that the LPN repeatedly used improper handwashing techniques while administering medications to multiple residents. For instance, after administering medications to a resident experiencing symptoms of a potential gastrointestinal infection, the LPN removed her personal protective equipment and washed her hands but used her arm to turn off the faucet. This improper technique was consistently observed during medication administration to several other residents, including those requiring blood glucose assessments and insulin injections. The LPN confirmed during an interview that she did not use a disposable towel to turn off the faucet after washing her hands. The surveyor discussed these handwashing concerns with the Nursing Home Administrator and the Director of Nursing, highlighting the facility's failure to adhere to its infection prevention and control program, specifically regarding hand hygiene procedures.
Plan Of Correction
1. Facility cannot retroactively correct. Employee 1 was immediately re-educated on proper handwashing technique, emphasizing the requirement to use a disposable towel to turn off faucets. 2. The Handwashing Policy was reviewed and reaffirmed with all staff. Copies of the policy and step-by-step handwashing guides are now posted at all handwashing stations. 3. Hand Hygiene Competency Checks and re-education on handwashing policy to be completed. All licensed nurses and CNAs will undergo a hand hygiene skills check-off by the Infection Preventionist or Director of Nursing (DON) and or designee to ensure compliance following the education on the facility's handwashing policy. 4. The DON, Infection Preventionist, or designee will conduct weekly random hand hygiene competencies for 4 weeks then monthly x 2 months. Audit findings will be documented and reviewed in monthly Quality Assurance & Performance Improvement (QAPI) meetings.