Failure to Perform Hand Hygiene Between Glove Changes During Medication Administration
Penalty
Summary
Nurse #2 failed to follow the facility's infection prevention and control program policies and procedures during a medication administration observation. Specifically, Nurse #2 did not perform hand hygiene before donning gloves, between glove changes, or immediately after removing gloves while administering multiple medications to a resident. The nurse was observed donning clean gloves without hand hygiene, using gloved hands to administer eye drops, removing gloves, donning new gloves without hand hygiene, administering nasal spray, and again removing gloves without performing hand hygiene. The nurse then adjusted the resident's oxygen tubing and handed the resident a medicine cup with pills using ungloved hands, followed by donning clean gloves without hand hygiene to apply a pain patch. Hand hygiene was only performed upon exiting the resident's room. The facility's policies clearly state that hand hygiene must be performed prior to donning gloves and immediately after removing them, and that glove use does not replace hand hygiene. During interviews, Nurse #2 acknowledged forgetting to use hand sanitizer between glove changes, and the Director of Nursing, who also serves as the Infection Preventionist, confirmed that the observed actions were not in accordance with facility policy.