Failure to Perform Hand Hygiene During Medication Administration
Penalty
Summary
Facility staff failed to perform appropriate hand hygiene during medication administration for a resident admitted with diagnoses including hypertension and myocardial infarction. During a medication pass, a registered nurse took the resident's blood pressure, recorded it, and proceeded to dispense medication without performing hand hygiene. The nurse only sanitized her hands after the surveyor intervened and pointed out the omission. Later in the same medication pass, the nurse shook hands with a visitor and then continued to dispense medications without performing hand hygiene until prompted by the surveyor. In interviews, the nurse acknowledged the failure to perform hand hygiene at the required times, and the Director of Nursing confirmed that facility policy requires hand hygiene before and after resident care, after leaving a resident's room, before handling the medication cart, and after contact with visitors.