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F0880
E

Failure to Perform Hand Hygiene and Sanitize Equipment During Medication Administration

Weatherford, Texas Survey Completed on 05-15-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

A deficiency was identified when a Licensed Vocational Nurse (LVN A) failed to adhere to infection prevention and control protocols during medication administration and vital sign monitoring for three residents. Observations revealed that LVN A did not perform hand hygiene before or after preparing and administering medications to the residents. Additionally, LVN A did not sanitize a reusable electronic wrist blood pressure cuff before or after use between residents. These lapses were observed during multiple medication passes and vital sign checks. During interviews, LVN A acknowledged not performing hand hygiene between resident interactions and not sanitizing the blood pressure cuff between uses. LVN A attributed the failure to not having alcohol-based hand rub (ABHR) readily available on the medication cart or in his pocket, despite the facility having an ample supply. He also demonstrated knowledge of the expectation to use sanitizer wipes for equipment but did not follow this practice during the observed medication administration and vital sign checks. Further interviews with the Registered Charge Nurse (RCRN) and Director of Nursing (DON) confirmed that facility expectations required hand hygiene before and after medication administration and equipment sanitization between each resident use. Review of facility policy supported these requirements, specifying hand hygiene after contact with residents or their equipment. LVN A's personnel file showed he had received infection control training during orientation.

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