Failure to Maintain Sanitary Medication Administration Practices
Penalty
Summary
During medication administration, a nurse was observed failing to follow sanitary procedures as required by facility policy. Specifically, the nurse was seen popping pills into her bare hand before placing them into medication cups, applying a medicated patch without washing her hands afterward, and touching multiple surfaces and personal items between medication passes without performing hand hygiene. The nurse administered medications to several residents, including controlled substances and a transdermal patch, and handled various items such as the medication cart, computer mouse, cabinet doors, and her personal water bottle, all without washing or sanitizing her hands between residents or after potential contamination. The facility's hand hygiene policy, revised in October 2023, requires handwashing immediately before and after resident contact, after touching contaminated surfaces, and after glove removal. Despite this, the nurse administered medications to 17 residents between hand washes and did not use hand sanitizer during the observed period. When questioned, the nurse acknowledged receiving infection control training but admitted to sometimes forgetting to wash her hands. The DON confirmed that nurses are expected to wash their hands between residents and are trained on these procedures before working independently.