Deficiencies in Hand Hygiene and Expired Supplies
Penalty
Summary
The facility was found to have deficiencies in food service safety and infection control practices during a recertification survey. A Certified Nursing Assistant (CNA) was observed assisting multiple residents with hand hygiene in preparation for dining without performing hand hygiene between residents. The CNA used bare hands and gloves inconsistently, failing to change gloves or sanitize hands between assisting different residents. This was observed for ten residents, indicating a lapse in following the facility's hand hygiene policy, which requires hand hygiene before and after resident contact and between handling food items. Additionally, the facility failed to ensure that disinfecting germicidal wipes and hand sanitizing solutions were discarded by their expiration dates. Expired hand sanitizers and disinfecting wipes were found in various locations, including the medication room, pantry, and central supply room. The Central Supply Representative admitted to not checking expiration dates, and the Infection Preventionist acknowledged that expired supplies would not be as effective. The Director of Plant Operations and Maintenance stated that the central supply person is responsible for checking the expiration of supplies. Interviews with staff, including the CNA, Registered Nurse, and Infection Preventionist, revealed a lack of adherence to infection control practices and oversight in monitoring the expiration of supplies. The CNA admitted to forgetting to change gloves and not performing hand hygiene between residents, while the Infection Preventionist and other staff did not identify concerns related to hand hygiene during their observations. The facility's policies on hand hygiene and inventory control were not effectively implemented, leading to these deficiencies.
Plan Of Correction
Plan of Correction: Approved January 31, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** F 880 483.80 Infection Prevention & Control SS=D I. The following actions were accomplished for the resident(s) identified in the sample: On [DATE], the Certified Nursing Assistant #4 who was assigned on the second-floor dining room was re-educated on the Facilities’ policy entitled “Hand Hygiene.” On [DATE], the hand sanitizer with an expiration date of [DATE] in the medication room on the second floor was immediately removed and replaced. On [DATE], the disinfecting wipe that was found on the 3rd floor panty room was immediately removed and replaced. On [DATE], the three sealed boxes containing expired disinfecting wipes that were found in the central supply with expiration dates of [DATE] were immediately removed and discarded. II. The following corrective actions will be implemented to identify other residents who may be affected by the same practice: All residents have been identified as potentially affected by the same practice. All Certified Nursing Assistants were educated on the facility policy entitled “Hand Hygiene” to ensure proper hand hygiene is practiced in between residents to prevent cross contamination. All hand sanitizer in the entire building were checked by housekeeping staff, including in the central supply, to ensure there were no other expired hand sanitizer. No additional expired hand sanitizer was identified. All disinfecting wipes in the entire building were checked by central supply, including within the central supply department, to ensure there were no other expired disinfecting wipes. No additional expired disinfecting wipes were identified. III. The following system changes will be implemented to ensure continuing compliance with regulations: The Infection Control Preventionist provided an education to all nursing staff on hand hygiene, emphasizing its importance during direct contact with residents in the dining room. This education focused on ensuring the staff members practice proper hand hygiene between residents and when donning or removing gloves, thereby minimizing the risk of cross contamination. The Director of Nursing and the Infection Control Preventionist reviewed the facility’s policy entitled “Hand Hygiene” and all regulatory components were outlined with no revision needed. The Infection Control Preventionist will continue to monitor hand hygiene protocols during meals times in the dining room to ensure all staff members adhere to compliance standards. All Housekeeping staff responsible for monitoring and changing hand sanitizers throughout the facility received education on the critical importance of routinely checking expiration dates. This education ensured that all hand sanitizers remain effective and safe for use, thereby maintaining a high standard of hygiene within the facility. All Central Supply staff/representative responsible for distributing supplies and managing procurement and inventory control within the facility received education on the vital importance of routinely checking expiration dates. This education specifically emphasized hand sanitizer and disinfecting wipes, ensuring that these products remain effective and safe for use, thereby supporting the overall health and safety of the facility. The Executive Director/Administrator and the Director of Plant Operations and Maintenance reviewed the facility’s policy entitled Purchasing, Stocking Inventory Control and Order Points Procedure was revised to incorporate comprehensive inventory control measures and monitoring protocols, ensuring that all supplies are routinely checked for expiration dates. IV. The facility’s compliance will be monitored utilizing the following quality assurance system: The Director of Nursing and Infection Control Preventionist will develop an audit tool to assess compliance with hand hygiene practices during mealtimes in the dining room. This audit tool will specifically focus on ensuring the staff members perform hand hygiene both during direct contact with residents and between residents. Quality Assurance Monitoring will be conducted by the Director of Nursing/Designee using a standardized audit tool titled “Hand Hygiene Compliance in Dining Room.” The audits will be conducted weekly for six months and/or until two quarters are at 100% compliance. A quantitative summary of findings and corrective actions will be reported monthly to the Quality Assurance Performance Committee by the Director of Nursing. The Executive Director/Administrator and the Director of Plant Operations and Maintenance will develop an audit tool to monitor compliance with inventory control measures and monitoring protocol ensuring that all supplies are routinely checked for expiration dates. Quality Assurance Monitoring will be conducted by the Director of Plant Operations and Maintenance/Designee using a standardized audit tool titled “Supply Inventory and Monitoring of Expiration Dates.” The audits will be conducted weekly for six months and/or until two quarters are at 100% compliance. A quantitative summary of findings and corrective actions will be reported monthly to the Quality Assurance Performance Committee by the Director of Plant Operations and Maintenance. Responsible: Executive Director/Administrator, Director of Nursing, Infection Preventionist and Director of Plant Operations are responsible for ensuring all above is in compliance.