Failure to Perform Hand Hygiene During Medication Administration
Penalty
Summary
The deficiency involves the facility’s failure to implement its infection prevention and control program by not ensuring staff performed required hand hygiene during medication administration. During multiple observations of medication passes, a Registered Nurse (Staff A) and a Licensed Practical Nurse (Staff C) repeatedly approached and used the medication cart, unlocked it, activated and typed on the computer, and prepared medications without performing hand hygiene. Staff A was observed popping multiple medications from blister packs directly into their bare hand before placing them into medication cups for several residents, and then entering resident rooms without hand hygiene, touching overbed tables, bed controls, and residents, and donning gloves without prior hand hygiene before taking blood pressures and administering medications. Staff A acknowledged during interview that they should not have touched the medications with their hands and should have used hand sanitizer more frequently. Similarly, Staff C was observed returning to the medication cart multiple times, unlocking it, activating and typing on the computer, and preparing medications for several residents without performing hand hygiene. Staff C then entered resident rooms without hand hygiene, touched overbed tables, bed controls, and residents, obtained blood pressures, and administered medications, and in some instances exited rooms and immediately began preparing medications for other residents without performing hand hygiene. During interview, Staff C stated they should have used the hand sanitizer available on the cart. Review of the facility’s “Hand Hygiene” policy, last approved on 1/15/2026, showed that hand hygiene is required before and after patient care and after contact with inanimate objects in the immediate patient vicinity, which was not followed in these observed instances.
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