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Based on observation, staff interview and review of hospital policy entitled, "IV (Intravenous) Medications - Continuous, IV Push and Piggyback" Registered Nurse (RN) #1 failed to disinfect the diaphragm on a medication vial prior to withdrawing the medication with a syringe during one (1) of two (2) IV medication observations. In addition, RN #1 failed to follow the hospital policy entitled, "Infection Prevention Hand Hygiene", by not performing hand hygiene after removing gloves. This had the potential to affect all patients served.

The findings include:

On 8/04/20 at 11:45 a.m. Registered Nurse (RN) #1 was observed preparing a dose of Solu-Medrol, 60 milligrams, to be administered via IV (intravenous) push to an un-sampled patient in room 332. During the observation RN #1 cleaned the countertop in the medication preparation room with a Cavi disinfect wipe while wearing gloves. RN #1 removed the gloves and immediately donned a fresh pair of gloves without performing hand hygiene. RN #1 then removed the medication vial cap and withdrew the medication into a syringe without disinfecting the diaphragm. RN #1 was observed entering room 332 and administering the medication via the patient's IV access.

During staff interview on 8/06/20 at 2:05 p.m., the Administrative Director and Manager of Quality, Safety and Reliability confirmed staff are to perform hand hygiene after removing gloves and should clean the diaphragm of a medication vial before withdrawing the medication, even if it is a new unopened vial.

Hospital policy, "IV Medications - Continuous, IV Push and Piggyback" revised 8/2019, reads "V. Aseptic technique should be used when preparing and administering IV medications, flush/locking solutions and other parenteral solutions administered by direct IV injection. Aseptic technique include: Hand hygiene prior to and after preparation and administration of the medication or solution as well as disinfection of the medication access diaphragm on a vial or the neck of an ampule prior to accessing the medication or solution." Hospital policy entitled, "Infection Prevention Hand Hygiene" effective 6/25/19, reads "Hand Hygiene Indications: 1.5 After glove removal."