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Based on record review, observation and interview, the facility failed to ensure that proper infection control practices were followed during the preparation of injectable medication when the vial's rubber septum was not disinfected with alcohol prior to the needle entering the vial in accordance with the Nicklaus Children's Hospital Safe Work Practices Policy for 1 (SP#4) of 6 sample patients (SP).

Findings Include:

Review of Physician's order for SP#4 dated 05/24/2022 at 1:16 PM documented ondansetron 8 milligrams (mg) = 4 milliliters (ml) intravenous (IV) every 8 hours as needed (PRN) for nausea/vomiting.

Observation of medication preparation on 05/24/2022 at 1:30 PM revealed Staff I (RN) verified medication order prior to entering the medication room. Staff I (RN) removed two vials of ondansetron from the Pyxis machine and performed the following steps:

(1) Hand hygiene performed and donned non-sterile gloves.
(2) Removed the tops from both vials and proceeded to prepare the syringe.
(3) Injected needle into the vial rubber septum.

Interview with Staff I (RN), Staff J (Clinical Practice Specialist) and Staff K (Clinical Educator) on 05/24/2022 at 1:30 PM revealed the medication vial rubber septum was considered sterile and did not require further disinfection.

The facility policy and proper infection control practices were not followed when the rubber septum on a medication vial was not disinfected with alcohol prior to the needle entering the septum when withdrawing medication from the vial.