Failure to Adhere to Hand Hygiene Protocols
Penalty
Summary
Staff failed to consistently offer or perform hand hygiene (HH) for residents after meals, as observed with multiple residents who were not provided HH following lunch. Interviews with staff confirmed that facility policy requires offering HH before and after meals for infection control, and staff acknowledged not following this policy during the observed incidents. The nurse manager also confirmed that HH should be offered to residents before and after meals to prevent infection. Additionally, staff did not perform HH prior to preparing medications or before and after donning gloves, as observed with a licensed psych technician during medication pass and glove use. Staff interviews confirmed awareness of the facility's policy to perform HH in these situations, and the facility's written policy also requires HH before and after eating, before preparing medications, and after removing gloves. These lapses were directly observed and verified by staff and the nurse manager during interviews.
Plan Of Correction
On 4/7/25-4/10/25, all staff were in-serviced on Hand Washing/Hand Hygiene Policy and Procedure (P&P) by the Director of Nursing (DON), Director of Staff Development (DSD), Assistant Director of Staff Development (ADSD), and Infection Preventionist (IP). The training included: 1) Offering Hand Hygiene (HH) to residents after meals 2) Utilizing HH prior to preparation of medications 3) Utilizing HH prior to donning and doffing of gloves The IP, DSD, and ADSD will observe and monitor: (1) Staff offering HH to residents after meals (2) Utilizing HH prior to preparation of medications (3) Utilizing HH prior to donning and doffing of gloves Audits will be conducted three times a week for 3 weeks, twice weekly for 2 weeks, and then once weekly for 1 week. Additionally, random audits will be performed for one month. System effectiveness will be evaluated during the facility's monthly Quality Assurance Performance Improvement Committee for three months.