Failure to Perform Proper Hand Hygiene During Medication Administration and Wound Care
Penalty
Summary
Staff failed to perform proper hand hygiene during three of nine direct care observations, as required by facility policy. Specifically, an LPN did not wash or sanitize her hands before setting up or administering medications to two residents, nor did she perform hand hygiene between medication administrations. The LPN acknowledged not following hand hygiene protocols and indicated a lack of immediate access to hand sanitizer on her medication cart. Additionally, a registered nurse did not change gloves or perform hand hygiene between the dirty and clean steps of a wound care procedure for a resident with chronic kidney disease and dementia. The RN removed soiled dressings, cleaned the wound, and applied new dressings without changing gloves or washing hands between steps, which was confirmed during an interview. Facility policies reviewed required hand hygiene between resident contacts and during wound care procedures, but these were not followed during the observed incidents.