Failure to Perform Hand Hygiene During Medication Administration
Penalty
Summary
A deficiency was identified when a registered nurse failed to perform hand hygiene during medication administration on the Main Unit hallway. Observations revealed that the nurse prepared and administered medications to multiple residents consecutively without sanitizing or washing hands between residents. This occurred during both the noon and afternoon medication administration periods, affecting nine residents directly and potentially impacting all 28 residents on the Main Unit hallway. The nurse only sanitized hands once during the observed period, despite handling medications for several residents in succession. During an interview, the nurse confirmed not performing hand hygiene between residents and acknowledged that facility policy requires hand sanitizing or washing before preparing medications and after administration. Review of facility policies indicated that hand hygiene is considered the primary means to prevent the spread of healthcare-associated infections, and staff are expected to follow established infection control procedures during medication administration. The deficiency was discovered incidentally during a complaint investigation.