Failure to Perform Hand Hygiene During Medication Administration
Penalty
Summary
The facility failed to maintain proper infection control practices during medication administration for one resident. Specifically, the Assistant Director of Nursing (ADON) was observed administering medications to a resident, then returning to the medication cart and preparing medications for another resident without performing hand hygiene. The ADON then administered medications to the second resident and exited the room without sanitizing or washing his hands at any point during the process. Both the ADON and the Director of Nursing (DON) acknowledged during interviews that hand hygiene should have been performed between residents, in accordance with infection control training and facility policy. The residents involved had significant medical histories, including diagnoses such as Parkinson's disease, laryngeal cancer, dementia, Alzheimer's disease, alcoholic cirrhosis of the liver, cellulitis, lung cancer, and a history of urinary tract infections. Facility records and care plans indicated that at least one resident was at risk for respiratory infections and confusion. The facility's policy for oral medication administration required hand hygiene before handling medications and after administration, which was not followed in this instance.