Failure to Perform Hand Hygiene During Resident Care and Medication Administration
Penalty
Summary
The facility failed to ensure proper hand hygiene practices were followed by staff during resident care and medication administration, as observed with three residents. Specifically, a registered nurse was seen exiting a resident's room without performing hand hygiene and then proceeded to handle medications and administer them to other residents without sanitizing hands between residents. The nurse also poured a vitamin D pill into their ungloved hand before placing it into a medication cup, contrary to infection control protocols. These actions were directly observed during medication passes and resident care activities. Interviews with the nurse, Director of Nursing, Administrator, and Infection Preventionist confirmed that facility policy requires hand hygiene before and after resident contact, as well as before and after medication administration. The nurse acknowledged awareness of these requirements but did not follow them during the observed incidents. Facility policies reviewed also emphasized the importance of hand hygiene and outlined specific procedures for staff to follow, which were not adhered to in these instances.