Infection Control Deficiency During Dining Task
Penalty
Summary
The facility failed to maintain proper infection control practices during a dining task, as observed during a recertification survey. Certified Nursing Assistant #7 did not perform hand hygiene between assisting multiple residents with hand hygiene before meal service. This was observed with 11 out of 24 sampled residents. The facility's policy requires staff to perform hand hygiene in accordance with CDC guidelines and to clean their hands between providing direct care to different residents. However, the CNA was seen picking up used hand wipes with bare hands and then using clean wipes to assist residents without cleaning their hands in between. Interviews conducted during the survey revealed that the CNA acknowledged the failure to perform hand hygiene, stating they were not thinking at the time. A Registered Nurse and the Assistant Director of Nursing both confirmed that hand hygiene is required between residents to prevent cross-contamination. The deficiency was noted under the regulation 10 NYCRR 415.19 (b)(4), highlighting the facility's failure to adhere to its own infection control policies and procedures.
Plan Of Correction
Plan of Correction: Approved March 5, 2025 I. Immediate Corrective Action 1. Resident # 1 had no ill effects from the CNA who did not conduct proper hand hygiene. 2. Resident # 8 had no ill effects from the CNA who did not conduct proper hand hygiene. 3. Resident # 26 had no ill effects from the CNA who did not conduct proper hand hygiene. 4. Resident # 31 had no ill effects from the CNA who did not conduct proper hand hygiene. 5. Resident # 39 had no ill effects from the CNA who did not conduct proper hand hygiene. 6. Resident # 44 had no ill effects from the CNA who did not conduct proper hand hygiene. 7. Resident # 54 had no ill effects from the CNA who did not conduct proper hand hygiene. 8. Resident # 82 had no ill effects from the CNA who did not conduct proper hand hygiene. 9. Resident # 102 had no ill effects from the CNA who did not conduct proper hand hygiene. 10. Resident # 145 had no ill effects from the CNA who did not conduct proper hand hygiene. 11. Resident # 157 had no ill effects from the CNA who did not conduct proper hand hygiene. 12. CNA # 7 was given Educational Counseling and 1:1 Inservice on Handwashing and Hygiene with emphasis on cleaning her hands in between residents while assisting multiple residents with hand hygiene before meal service. II. Identification of Others 1. The facility respectfully acknowledges that all residents have the potential to be affected by these deficient practices. 2. The RN supervisors conducted a meal observation on each unit for lunch on 2/6/2025 to ensure that the CNAs were performing proper hand hygiene in between residents while assisting multiple residents with hand hygiene before meal service. 3. No further issues were identified. III. System Changes 1. The Administrator, Medical Director and DNS reviewed the policy on “Handwashing and Hygiene” and found it to be compliant. 2. The Administrator, Medical Director and DNS reviewed and revised the policy on “Dining Meal Service” to include the CNA performing proper hand hygiene in between residents while assisting multiple residents with hand hygiene before meal service. 3. RN, LPN and CNA will be inserviced on the “Handwashing and Hygiene” policy and the policy on “Dining Rooms Meal Service” with emphasis on performing proper hand hygiene in between residents while assisting multiple residents with hand hygiene before meal service. 4. A copy of the Lesson Plan and Attendance filed for reference and validation. IV. Quality Assurance 1. The DNS / ADNS developed an audit tool to ensure that the CNAs were performing proper hand hygiene in between residents while assisting multiple residents with hand hygiene before meal service. 2. Audits will be done by the RN Supervisor / Designee on 10 meals weekly x 4 weeks, 10 meals monthly x 3 months and 10 meals quarterly thereafter. 3. Audits with negative findings will have an immediate corrective action taken by the DNS and reported to the Administrator for review & follow up. 4. Audit findings will be presented to the QA Committee quarterly by the DNS. V. The DNS is responsible for overseeing this plan of correction by 4/7/2025.