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Based on observations, interviews, and document review the facility failed to provide safe handling and preparation of medications administered to patients in 3 of 3 medication administration observations (Patients A, B, and C).

This failure created the potential for patients to contract a healthcare acquired infection secondary to improper hand hygiene while administrating medications.

FINDINGS:

POLICY

According to Hand Hygiene, all staff are required to perform hand hygiene prior to any direct patient contact even if gloves are to be worn, before and after any direct patient contact or contact with the patient's environment, and after touching any inanimate sources that are likely to be contaminated with microorganisms.

1. The facility failed to provide safe handling of medication to ensure protection of healthcare acquired infections.

a) On 10/18/16, 3 observations of patient medication administrations were observed and revealed the following missed opportunities for hand hygiene:

i) At 9:30 a.m., Registered Nurse (RN #1) was observed providing care to Patient A in the Internal Medicine and Oncology Unit. With bare hands, RN #1 picked up the electric cord of a blood pressure machine from the floor and plugged it into an electric socket located on the wall of Patient A's room. RN #1 then obtained Patient A's vitals, touched the computer keyboard in the patient's room. Without performing hand hygiene, RN #1 then proceeded to handle and administer Patient A's oral medications and changed the intravenous (IV) fluid infusing into Patient A's IV site.

An interview was conducted with RN #1 after the medication administration was completed. After reviewing his/her actions during the medication administration, RN #1 stated s/he should have performed hand hygiene after handling the potentially contaminated electric cord and before having direct contact with Patient A and his/her medications.

ii) At 11:55 a.m., RN #2 and RN #3 were observed preparing to administer an insulin injection for Patient B in the Telemetry Unit. RN #2 scanned the insulin vial's label into the bedside computer, then donned gloves without performing hand hygiene. While preparing to administer the injection, an alcohol pad fell to the floor. RN #3 picked up the alcohol pad and handed it to RN #2, who proceeded to open the alcohol pad, swab Patient B's right arm with the pad and administer the injection.

An interview was conducted with RN #2 after the medication administration was completed. After reviewing his/her actions during the medication administration, RN #2 stated s/he should have changed gloves, performed hand hygiene and used a different alcohol pad to clean Patient B's arm before administering the injection.

iii) At 12:15 p.m., RN #4 and RN #5 were observed preparing to administer fresh frozen plasma (FFP), a blood product, to Patient C on the Internal Medicine and Oncology Unit. Upon entering Patient C's room, RN #4 and RN #5 performed hand hygiene and donned gloves. RN #4 obtained Patient C's temperature and vital signs while RN #5 entered information into the bedside computer. Both RNs were observed touching patient, the computer keyboard and IV pole during the preparation of the FFP administration. Without performing changing gloves and performing hand hygiene, RN #4 scrubbed Patient C's IV access with an alcohol pad while RN #5 attached the bag of FFP to IV tubing and primed the tubing. RN #4 then attached the IV tubing to Patient C's IV access site and began infusing the FFP.

An interview was conducted with RN #5 after the infusion of FFP was initiated. After reviewing the actions of both RN's, RN #5 stated they both should have changed gloves and performed hand hygiene before spiking the bag of FFP and administering it to Patient C.

b) On 10/19/16 at 1:05 p.m., an interview with the Nursing Director of Inpatient Services (Director #6) was conducted. Director #6 stated staff were expected to perform hand hygiene after being contaminated from touching the floor and before performing a clean procedure such as administering medications. Director #6 then stated the facility had found increased compliance of staff performing hand hygiene upon entering and exiting patients' rooms after implementing a hand hygiene tracking system; however, the tool did not measure hand hygiene compliance while staff were in patients' rooms.

c) On 10/19/16 at 1:31 p.m., an interview with the Infection Prevention Specialist (IP#7) was conducted. IP #7 stated staff were expected to change gloves and perform hand hygiene before accessing patients' IV accesses and administering medications.