Infection Control Deficiencies in Hand Hygiene and Wound Care
Penalty
Summary
The facility failed to maintain proper infection control practices, as observed during a recertification survey. A Certified Nursing Assistant (CNA) was seen assisting multiple residents with hand hygiene in the dining room without performing hand hygiene between residents. The CNA used bare hands to distribute hand wipes and assist residents, failing to wash hands between interactions, which is against the facility's hand hygiene policy. This oversight was acknowledged by the CNA during an interview, where they admitted to not noticing the lapse in hand hygiene during the dining service. Additionally, a Licensed Practical Nurse (LPN) did not adhere to infection control protocols during a wound care procedure for a resident with a stage 4 pressure ulcer. The LPN placed supplies on the resident's mattress, failed to wash hands between glove changes, and did not wear a gown as required by the facility's Enhanced Barrier Precautions policy. The LPN acknowledged forgetting to wash hands between glove changes and not using a gown during the procedure, despite being trained on these protocols. The resident involved in the wound care incident had a history of stroke, neurogenic bladder, and hemiplegia, and was admitted with a stage 4 pressure ulcer. The facility's policies require specific infection control measures, including the use of gowns and gloves during high-contact care activities, especially for residents with wounds. Interviews with the Wound Care Coordinator and the Director of Nursing confirmed that staff had been educated on these precautions, but the observed practices did not align with the training provided.
Plan Of Correction
Plan of Correction: Approved January 16, 2025 Element 1 F880: The CNA's who were observed failing to follow hand hygiene, particularly in between resident interactions, were in-serviced. Provided on the spot training and counseling to the CNAs regarding proper hand washing. Ensured all hand washing wipes were available in the dining room and other resident care areas. The identified LPN was immediately educated and retrained on proper infection prevention and control protocols, including hand hygiene and the use of personal protective equipment. All residents involved were assessed for any potential risks of infection. No adverse outcomes were identified. Element 2: All residents have the potential to be affected by this practice. The Infection Control Practitioner/or designee will monitor all CNA's, LPNs, and RNs for adherence to proper infection control practices. Proper handwashing and the proper use of personal equipment will be included in this routine monitoring. Immediate corrective action, such as re-education or disciplinary action, will be implemented for identified infection control breaches. Training sessions will be documented, and staff will be required to demonstrate competency. An audit tool was developed to monitor for compliance. Element 3: Systemic changes: On (MONTH) 10, 2025, the Administrator, Medical Director, Director of Nursing, and Infection Preventionist reviewed the facility's Infection Control Policy and Procedures for Handwashing between residents and the proper use of personal protective equipment; no revisions were required. Education will be provided to all CNAs, LPNs, and RNs related to general infection prevention and control practices. Education will emphasize the staff member's responsibility for proper handwashing. Education will continue to be provided to all staff during orientation and annually, and on an as-needed basis related to general infection prevention and control practices and protocol. In addition to hand hygiene competency upon hire and annually, the facility will conduct periodic hand hygiene competencies on handwashing and infection control practices. Element 4: Monitoring of corrective action: The facility will develop an audit tool to monitor compliance with Infection Prevention and Control protocol related to proper hand washing. On a weekly basis for one quarter, the DNS/designee will observe 2-5 direct care staff for proper handwashing technique and proper use of PPE. Any outstanding issues will be addressed immediately. All audit findings will be reported to the Administrator monthly for 3 months. All audit findings will be reported to the QAPI Committee for 1 quarter for evaluation, discussion, and follow-up. At this time, the QAPI Committee will make a determination for the need for ongoing auditing. The Infection Preventionist will continue to report a summary of all infection control activities and audit findings to the QAPI Committee for one quarter. The QAPI Committee will determine if further action is required. Element 5: Persons responsible: Director of Nursing and Infection Preventionist.