Failure to Perform Hand Hygiene During Medication Pass and Meal Delivery
Penalty
Summary
Facility staff failed to perform proper hand hygiene during medication administration and meal tray delivery, resulting in a deficiency under infection prevention and control standards. During a medication pass, a registered nurse dropped several medications onto the top of a medication cart, which was not clean, and then used her bare, ungloved hand to pick up the medications and place them into a medication cup. The nurse then crushed the medications, mixed them with applesauce, and administered them to a resident with severe cognitive impairment and multiple chronic conditions, including heart failure and atrial fibrillation. Additionally, the dietary manager was observed delivering lunch trays to three different residents without performing hand hygiene between each delivery. The dietary manager entered each resident's room, removed the food tray lid, touched items on the tray and the food delivery cart, and exited the room without using the hand sanitizer dispensers that were available in each room. The dietary manager confirmed during an interview that she did not wash her hands or use hand sanitizer between meal tray deliveries, acknowledging awareness of the proper procedure but stating she did not often deliver trays. A review of the facility's hand hygiene policy indicated that employees are required to use alcohol-based hand rub or wash hands after touching a patient's environment. The observed failures to follow this policy during both medication administration and meal tray delivery directly contributed to the cited deficiency in infection prevention and control.
Plan Of Correction
F880 The facility failed to ensure proper infection control measures when: A) The RN #204 dropped medication for resident #15 on the medication cart during medication administration, then placed medication in a medication cup. B) The Dietary Manager #208 assisted with passing meal trays on the B-front hall without performing proper hand hygiene during tray pass for residents #98, #5, and #99. Step 1: The facility DON immediately educated A) the RN #204 on proper maintenance of infection control practices during medication administration and B) the Dietary Manager #208 on proper hand hygiene practices while passing meal trays. Hand Hygiene competencies were completed on both individuals as well. Completed on 6/10/25. Step 2: This has the potential to affect residents #15, #98, #5, #99; The DON will assess the identified residents #5 and #15 for potential effects on 7/10/25. Unable to assess #98 and #99 as these residents are not identified on the resident identifier list provided by the ODH Surveyors. Step 3: To prevent this from recurring, the DON or designee will educate A) licensed nurses on proper infection control principles during medication administration and B) staff that assist with meals on proper hand hygiene during the meal process. Completed on 7/11/25. Step 4: To monitor and maintain ongoing compliance, the DON or designee will audit A) maintenance of proper infection control practices during medication administration 2x per week x4 weeks then 2x per month x2 months and B) use of proper hand hygiene during tray pass 3x per week x4 weeks then monthly x2 months. Audits will begin 7/14/25. The results of the audits will be forwarded to the facility QAPI committee for further review and recommendations.