Failure to Perform Hand Hygiene and Sanitize Shared Equipment During Medication Pass
Penalty
Summary
Staff failed to consistently perform hand hygiene and sanitize shared medical equipment during medication passes, as observed during two of four medication administration events. In one instance, an LPN prepared and administered medication to a resident without performing hand hygiene before or after the process, despite facility policy requiring the use of alcohol-based hand rub or soap and water before and after direct resident contact and medication handling. The LPN acknowledged the omission when questioned and subsequently obtained hand sanitizer from the nurses' unit. In another instance, a different LPN also did not perform hand hygiene before or after administering medications to a resident and used a shared blood pressure cuff without sanitizing it before or after use. The LPN admitted to not sanitizing her hands and was unsure about the cleaning protocol for the blood pressure cuff. Review of facility policies confirmed the expectation for staff to perform hand hygiene before and after resident contact and medication administration, as well as to clean and disinfect multi-resident use equipment after each use. The Director of Nursing confirmed these expectations in an interview, stating that staff are required to follow these protocols. The observed failures to adhere to these policies during medication passes constituted deficiencies in the facility's infection prevention and control program.