Infection Control Lapses in Hand Hygiene, PPE Use, and Sanitation
Penalty
Summary
The facility failed to adhere to established infection prevention and control practices, as evidenced by multiple observed lapses in hand hygiene, personal protective equipment (PPE) use, and sanitation procedures. Staff were observed entering and exiting rooms of residents on transmission-based precautions, including isolation and contact plus precautions, without performing required hand hygiene. In one instance, a certified nursing assistant (CNA) handled clean hospital gowns and moved between resident rooms without sanitizing hands, despite signage indicating the need for hand hygiene and PPE. The infection control preventionist confirmed that hand hygiene should be performed when entering and exiting rooms of residents on precautions. In another case, a resident on Enhanced Barrier Precautions due to surgical wounds was provided direct care by a CNA who wore gloves but failed to don a gown during high-contact activities such as incontinence care and repositioning. During wound care for the same resident, a nurse was observed changing gloves multiple times without performing hand hygiene between glove changes. Both the CNA and nurse acknowledged awareness of the required precautions but did not follow them during care. Additional deficiencies were observed during meal service, where staff did not offer or perform hand hygiene for residents before meals, nor did they sanitize their own hands between assisting different residents. Medication carts were found to be dirty, with soiled and sticky drawers, and a nurse was observed touching a resident's medication with her bare finger during preparation. Facility policies reviewed by surveyors outlined the expectations for hand hygiene, PPE use, and sanitation, but these were not consistently followed by staff.