Failure to Perform Hand Hygiene During Medication Pass
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program related to hand hygiene during medication administration. On 01/12/2026 at 8:57 AM, an RN (V5) prepared oral medications and an inhaler for resident R43, entered the resident’s room, handed the medications and water to the resident, and then provided an inhaler followed by water for swish and spit. The resident returned the cup and inhaler to the RN, and at no point before, during, or after this medication administration did the RN perform hand hygiene. At 9:10 AM the same day, the RN prepared oral medications for resident R40, entered the room, handed the medications and water to the resident, and disposed of the used cups before leaving the room, again without performing hand hygiene before or after medication administration. On 01/12/2026 at 9:25 AM, the RN prepared oral medications for resident R63, entered the room, handed the medications and water to the resident, and responded to the resident’s request for more water by taking the resident’s Styrofoam cup and stating she would refill it after the medications were taken. The RN then provided additional small cups of water as the resident continued taking medications and later filled the resident’s cup with ice from the 100 Hall ice chest, without performing hand hygiene at any point before, during, or after this process. On 01/13/2026 at 10:32 AM, the RN stated she was unsure of the facility’s expectations regarding hand hygiene during medication administration, although she agreed it should be performed between each resident. The DON (V2) later stated her expectation that nursing staff perform hand hygiene prior to preparing medications, after administering medications, and whenever hands are visibly soiled. The facility’s written Handwashing/Hand Hygiene and Medication Administration policies require adherence to recognized hand hygiene procedures, including washing hands before beginning a medication pass, prior to handling medications, after direct resident contact, and using approved hand sanitizer between handwashings when appropriate.
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