Failure to Follow Infection Control Protocols for Equipment and Hand Hygiene
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by multiple instances of staff not following established protocols for cleaning and hand hygiene. During medication administration, a medication aide (MA) used a blood pressure cuff on several residents consecutively without sanitizing the equipment between uses, despite having been trained to do so. The aide acknowledged awareness of the protocol but stated she forgot to disinfect the cuff, which was confirmed by direct observation and staff interviews. Additionally, certified nursing assistants (CNAs) did not adhere to proper hand hygiene practices during incontinence care. One CNA changed gloves without performing hand hygiene between glove changes, while another failed to change gloves and perform hand hygiene before placing a clean brief on a resident. Both CNAs had received training on infection control and recognized the importance of these practices but admitted to forgetting the required steps during care. The residents involved had significant medical histories, including conditions such as cerebral infarction, type two diabetes, urinary tract infection, major depressive disorder, and cerebrovascular disease. Facility policy required cleaning and disinfection of non-critical resident care items, such as blood pressure cuffs, and mandated hand hygiene before moving from contaminated to clean body sites and after glove removal. Despite these policies and recent staff training, the observed lapses in infection control protocols led to the identified deficiencies.