Failure to Perform Hand Hygiene and Label IV Catheter
Penalty
Summary
A Licensed Vocational Nurse (LVN) failed to perform proper hand hygiene during medication administration for a resident with multiple complex medical conditions, including dysphagia, diabetes mellitus type II, epilepsy, hypertension, blindness, and gastrostomy status. The LVN prepared and administered several medications via gastrostomy tube without performing hand hygiene before donning gloves and gown, and again failed to perform hand hygiene after changing gloves during the process. The LVN later acknowledged forgetting to sanitize her hands, despite being aware of the facility's protocols requiring hand hygiene before and after resident contact, and before donning and after doffing personal protective equipment (PPE), especially for residents on Enhanced Barrier Precautions. The facility's Infection Preventionist Nurse confirmed that staff are required to perform hand hygiene before any high-contact activity, such as medication administration via gastrostomy tube, and before and after using PPE. Facility policy also specifies that wearing gloves does not replace the need for hand hygiene, and that hand hygiene must be performed before donning and after doffing PPE, as well as upon entering and exiting resident rooms. The LVN's failure to follow these protocols was observed during a medication pass and confirmed in subsequent interviews. Additionally, a Registered Nurse (RN) failed to label and date a peripheral intravenous (IV) catheter for another resident. The RN and Director of Nursing both stated that IV sites must be labeled with the date, time, and nurse's initials at the time of insertion to track when the IV needs to be replaced. Facility policy requires this labeling to prevent infection at the IV site. The omission was observed and confirmed through interviews and review of facility policy.