Failure to Ensure Consistent Hand Hygiene by Staff
Penalty
Summary
Staff failed to consistently perform proper hand hygiene during resident care, as observed on multiple occasions. Certified Nursing Assistants (CNAs) were seen entering and exiting resident rooms without using the alcohol-based hand sanitizer dispensers, which were operational and adequately supplied. One CNA entered a room in response to a call light without performing hand hygiene, while another left and re-entered a room with clean linens without using hand sanitizer. A third CNA also entered a resident's room without hand hygiene. These lapses occurred despite the facility's policy requiring hand hygiene to prevent the spread of infection. Interviews with the involved CNAs revealed that they had received in-service training on hand hygiene from the Infection Preventionist (IP) nurse and were aware of the facility's expectations. However, they admitted to sometimes forgetting to perform hand hygiene, especially when in a hurry. The IP nurse and Director of Nursing (DON) confirmed that staff had been instructed on proper hand hygiene procedures, including the use of soap and water after personal care and alcohol gel when entering and exiting resident rooms.