Failure to Perform Hand Hygiene During Medication Administration
Penalty
Summary
Staff F, a Registered Nurse, failed to perform hand hygiene during multiple medication administration events for three residents. Observations showed that Staff F repeatedly returned to the medication cart, handled keys, unlocked the cart, used the computer, and prepared medications without performing hand hygiene. On one occasion, Staff F donned gloves without hand hygiene, pierced a medication bottle with a gloved hand, and then assisted a resident in bed repositioning and medication administration without washing hands before or after glove use. The same pattern of neglecting hand hygiene was observed during medication preparation and administration for two additional residents, including handling gloves that had fallen on the floor and applying topical medication without appropriate hand hygiene before or after glove use. Interviews with Staff F confirmed awareness of the hand hygiene lapse, attributing the failure to nervousness during observation. The Director of Nursing stated that all staff are expected to follow infection control standards for handwashing during medication administration. Review of the facility's hand hygiene policy confirmed that hand hygiene is required before and after resident contact, after touching the resident's environment, and after glove removal, and that glove use does not replace hand hygiene.