Failure to Ensure Hand Hygiene During Medication Pass and Meal Service
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program as evidenced by staff not adhering to proper hand hygiene protocols during medication administration and meal service. During medication passes, a licensed nurse prepared and administered medications to two residents without performing hand hygiene or wearing gloves as required. One nurse handled a resident's partially eaten meal tray and then prepared medication without washing hands, incorrectly stating that gloves could be used in place of handwashing. The Infection Preventionist and Director of Nursing both confirmed that facility policy requires hand hygiene before and after resident contact and before medication preparation, and that gloves are not a substitute for handwashing. Review of facility policy corroborated these expectations. Additionally, staff did not ensure that residents performed hand hygiene before eating lunch in the dining room. Observations showed that none of the 24 residents present were offered hand hygiene before receiving their meals, and residents confirmed that their hands were not washed or wiped prior to eating. Staff interviews revealed that the expectation was for residents to clean their hands with a moist towelette provided on their meal trays, but no such towelettes were present. Facility policy also indicated that residents should be encouraged to practice hand hygiene. These lapses in infection control practices were confirmed through interviews and policy review.