Failure to Perform Hand Hygiene During Medication Administration
Penalty
Summary
Staff failed to perform proper hand hygiene during medication administration for three residents observed. Specifically, a registered nurse was seen repeatedly accessing the medication cart, preparing medications, and entering residents' rooms without using hand sanitizer or washing hands before donning gloves or after removing them. The nurse administered medications through various routes, including intravenous and gastrostomy tube, and handled invasive devices such as a midline catheter, all without performing hand hygiene as required by facility policy. The facility's policy clearly states that hand hygiene must be performed before and after direct resident contact, before preparing or handling medications, before and after handling invasive devices, and after removing gloves or personal protective equipment. Despite this, the nurse did not follow these procedures during multiple medication passes. Both the nurse and the Director of Nursing acknowledged that the expected infection control standards were not followed during these observations.