Failure to Perform Hand Hygiene During Medication Administration
Penalty
Summary
The facility failed to ensure appropriate infection control practices, specifically hand hygiene, during medication administration for five residents. Multiple observations revealed that nursing staff, including RNs and LPNs, did not perform hand hygiene before or after preparing and administering medications. For example, a nurse was seen administering medications to residents without washing or sanitizing hands, even after touching various surfaces and resident items such as control pads, call lights, bedside tables, and blankets. In one instance, a nurse removed a Band-Aid and touched a computer screen before handling medications, again without performing hand hygiene. These lapses were observed during several medication passes, both in resident rooms and common areas, and involved direct contact with residents and their personal items. The facility's own policy, dated February 2025, requires hand washing or sanitizing prior to medication administration to prevent contamination or infection. Despite this policy, staff did not consistently follow these procedures, as confirmed by direct observation and acknowledged by facility leadership.