Failure to Perform Hand Hygiene and Follow Infection Control Protocols
Penalty
Summary
Staff failed to perform proper hand hygiene and follow infection prevention protocols during care for multiple residents. In one instance, an LPN did not sanitize hands before retrieving and preparing intravenous medication for a resident with a PICC line, did not place a barrier on the bedside table before setting down supplies, and did not sanitize the IV tubing before connecting it to the resident’s line. The LPN acknowledged these lapses during an interview, and the DON confirmed that hand hygiene and use of barriers were expected per facility policy. In another case, a CNA performed peri-care for a resident who required assistance with activities of daily living but did not remove gloves or perform hand hygiene after completing care. The CNA then handled and stored supplies, including ointment and soap, with soiled gloves. The CNA later stated that gloves should have been changed and hands washed before handling supplies, and the DON confirmed that this was the expected procedure according to facility policy. A similar deficiency occurred during catheter care for another resident on Enhanced Barrier Precautions due to an indwelling catheter. The CNA did not remove gloves or perform hand hygiene after completing catheter care and, while still wearing soiled gloves, handled the resident’s wash basin and other supplies. The DON stated that for residents on Enhanced Barrier Precautions, staff are expected to wash hands, don appropriate PPE, and change gloves and perform hand hygiene after care and before handling supplies. Facility policies reviewed supported these expectations for infection prevention and control.