Failure to Perform Hand Hygiene and Sanitize Shared Equipment During Medication Pass
Penalty
Summary
During a medication pass, a registered nurse (RN) failed to perform hand hygiene at multiple critical points, including before preparing medications, after returning from the medication room, after entering and exiting resident rooms, and before donning and after removing gloves. The RN also neglected to sanitize hands between caring for different residents and after handling shared medical equipment. These actions were observed during the care of four residents, where the RN repeatedly moved between rooms and tasks without following hand hygiene protocols as outlined in the facility's policies. In addition to lapses in hand hygiene, the RN did not properly clean and disinfect shared medical equipment, such as a blood pressure (BP) machine and glucometer, between resident uses. The BP machine was used on multiple residents without being sanitized, and the glucometer was only wiped with small alcohol prep pads instead of the required EPA-approved disinfectant wipes. The RN expressed a misunderstanding about the necessity of cleaning the BP cuff, believing it was only required for equipment exposed to blood. Interviews with the Infection Control Nurse and the Director of Health Services confirmed that facility policy requires hand hygiene before and after resident contact, before donning gloves, and after glove removal, as well as cleaning and disinfecting shared equipment between each use. The observed failures to follow these protocols were acknowledged by the RN, who later admitted to the surveyor that he should have sanitized both his hands and the BP cuff between residents.