Failure to Perform Hand Hygiene During Resident Care and Water Pass
Penalty
Summary
The facility failed to ensure proper hand hygiene practices were followed by staff during routine care activities, specifically during the distribution and collection of water mugs and during catheter care. Certified Nurse Aide (CNA) "A" was observed delivering fresh water and removing used water mugs from multiple residents' rooms without performing hand hygiene between rooms. CNA "A" admitted to not using hand sanitizer between rooms and acknowledged the importance of hand hygiene in preventing cross-contamination. During catheter care for a resident, CNA "O" and CNA "C" donned gloves as part of Enhanced Barrier Precautions. CNA "O" performed perineal care and, without removing contaminated gloves, touched environmental surfaces such as closet handles and retrieved a clean incontinence brief. The same contaminated gloves were used to change the resident's brief and assist with clothing and protective boots. CNA "O" acknowledged that hand hygiene and glove changes should have occurred after cleaning the resident's genitals and catheter tubing. A registered nurse confirmed that gloves should be removed and hand hygiene performed before touching other surfaces. The facility's hand hygiene policy requires staff to perform hand hygiene before donning gloves and immediately after removing them, emphasizing that glove use does not replace hand hygiene. The Director of Nursing was made aware of the observations and expressed understanding of the deficiency related to the failure to perform hand hygiene and the potential for cross-contamination within the facility.
Plan Of Correction
The facility will develop a plan to ensure hand hygiene will be performed during a fresh water pass and post catheter care. For resident #11, DON and ADON monitored daily nursing notes on the 24-hour report for any signs or symptoms of potential infection. None noted. For resident #32, DON and ADON monitored daily nursing notes on the 24-hour report for any signs or symptoms of potential infection. None noted. For resident #33, DON and ADON monitored daily nursing notes on the 24-hour report for any signs or symptoms of potential infection. None noted. For resident #38, DON and ADON monitored daily nursing notes on the 24-hour report for any signs or symptoms of potential infection. None noted. For resident #50, DON and ADON monitored daily nursing notes on the 24-hour report for any signs or symptoms of potential infection. None noted. For resident #52, DON and ADON monitored daily nursing notes on the 24-hour report for any signs or symptoms of potential infection. None noted. For resident #55, DON and ADON monitored daily nursing notes on the 24-hour report for any signs or symptoms of potential infection. None noted. Housekeeping disinfected the high-touch surfaces in room. The DON/ADON and designees identify residents on Enhanced Barrier Precautions who were potentially affected. For any identified, the DON/ADON will monitor daily nursing notes on the 24-hour report for any signs or symptoms of potential infection. Immediate 1:1 education was provided to Resident Assistants in the facility on proper hand hygiene protocol between residents when passing water jugs. All others were educated before or during their next working shift. DON and ADON completed policy reviews on the following: 1) Hand Hygiene Policy reviewed and updated to indicate when it's appropriate to perform hand hygiene: a. Perform Hand Hygiene before and after: i. Performing invasive procedures ii. Handling medications iii. Handling contaminated items iv. Contact with blood and body fluid, secretions, excretions, mucous membranes, etc v. Assisting with/providing personal care vi. Eating vii. Using the restroom viii. Sneezing, coughing, blowing or wiping nose. b. When in doubt, wash your hands. 2) Catheter Care Policy—updated to indicate it’s appropriate to remove gloves and perform hand hygiene after performing catheter care but before touching clean items. Then don new, clean gloves. 3) Drinking Water Distribution Policy—updated to indicate hand hygiene is to be performed before entering a resident’s room and after placing the empty jug on the cart. DON and ADON created an education module with posttest on Relias for: 1) All Resident Assistants on performing hand hygiene between resident rooms 2) All CNAs on when to perform hand hygiene after performing catheter care, but before touching clean items such as closet handle, clothing, or clean brief. Per facility policy, you are required to remove gloves, perform hand hygiene, and don new, clean gloves. For those employees who are casual/student status, on vacation, or on LOA, training will be completed before/during their next scheduled shift. To ensure compliance with hand hygiene after education, DON/ADON or designee will perform hand hygiene audits during a water pass 6x/week for 2 weeks, 4x/week x 2 weeks, then 2x weekly for two months. Audits for hand hygiene for residents on Enhanced Barrier Precautions will be completed by DON/ADON or designee with focus on reducing the risk for cross-contamination. Two audits weekly for 1 month, one audit weekly for 2 months. The DON will present a compliance report based on the audit findings to be reviewed during monthly QAPI meetings by the team for 3 months, with recommendations by QAPI for further monitoring if consistent compliance has not been achieved. DON will be responsible for attaining and sustaining overall compliance with this plan of correction.