Failure to Perform Hand Hygiene During Medication Administration
Penalty
Summary
Facility staff failed to perform proper hand hygiene during medication administration, as observed with two staff members. One registered nurse was seen entering resident rooms and administering medications, including eye drops and a medication patch, without performing hand hygiene before or after resident contact, after glove removal, or after touching the resident's environment. The nurse also handled personal items and the medication cart without cleaning their hands between tasks. Another nurse, an LPN, was observed providing intravenous medication under enhanced barrier precautions, but removed their gown and gloves and exited the room without performing hand hygiene, then accessed the medication cart and continued down the hallway. A family member reported that nurses did not wash their hands when entering or leaving the resident's room and did not use gloves or perform hand hygiene when administering eye drops. The facility's policy required hand hygiene before and after resident contact, after touching the resident's environment, and immediately after glove removal. The Director of Nursing confirmed that staff were expected to follow these protocols, but observations and interviews demonstrated that these procedures were not consistently followed.