Failure to Follow Hand Hygiene Protocols During Medication Administration
Penalty
Summary
The facility failed to ensure proper infection control practices during medication administration for two residents. In one instance, a registered nurse administered oral medications to a resident with Parkinson's Disease, Diabetes, and Chronic Kidney Disease, and then immediately proceeded to administer eye drops without changing gloves or performing hand hygiene. This action was observed during a medication pass and was not in accordance with the facility's hand hygiene policy, which requires hand hygiene after contact with objects in the resident's vicinity and after removing personal protective equipment. In another instance, a registered nurse performed hand hygiene but turned off the faucet with her wet hand after washing, rather than using a clean paper towel as required by policy. This occurred during medication administration for a resident with a history of infection and inflammatory reaction due to cardiac and vascular devices, acute respiratory failure, and pyelonephritis. The Director of Nursing confirmed during interviews that these actions were not consistent with facility policy.