Failure to Follow Infection Control During Medication Administration
Penalty
Summary
Nurse #3 was observed during a medication pass preparing several medications for a resident. While popping a pill out of a bubble pack, the pill missed the medication cup and landed on the top of the medication cart. Nurse #3 picked up the pill with her bare fingers and placed it in the medication cup, then administered the medications to the resident. She had last performed hand hygiene before starting to prepare the medications and, during the process, touched multiple medication bottles, bubble pack cards, and drawer handles on the cart. The top of the medication cart was not cleaned at any time during the observation. In interviews following the incident, Nurse #3 acknowledged that she should have discarded the pill after it touched the cart and her bare hands, recognizing this as proper infection control procedure. The Infection Preventionist, NP, and DON all confirmed that the correct action would have been to throw away the contaminated pill, as both the cart and hands could transmit disease-causing organisms. The Director of Clinical Services stated there was no specific policy addressing this scenario, but the Administrator indicated that standard nursing practice would be to discard the pill and obtain a clean one.