Failure to Follow Hand Hygiene Protocols During Resident Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by multiple staff not adhering to hand hygiene protocols during personal and wound care for two residents. During peri care for a male resident with severe cognitive impairment and chronic medical conditions, a CNA was observed gathering supplies after exiting another resident's room without washing her hands. Although the CNA performed some handwashing steps, she did not consistently follow the facility's policy for hand hygiene, including not washing hands for the required duration and failing to wash hands after providing care and removing gloves. In a separate incident, two CNAs provided peri and wound care for a female resident with a history of urinary tract infection and incontinence. Both CNAs washed their hands before donning gloves and performing care, but after completing the care and removing gloves, neither washed their hands as required by facility policy. Additionally, one CNA failed to adequately clean the resident, leaving visible soiling until prompted by a surveyor to continue cleaning. Both CNAs acknowledged their training in infection control and hand hygiene but did not adhere to the established procedures during the observed care. Record reviews confirmed that the facility's policies require hand hygiene before and after glove use, after resident care, and after contact with soiled materials. Interviews with staff and administration indicated awareness of the policies and the importance of hand hygiene, but the observed actions did not align with these requirements. The failure to follow proper hand hygiene and infection control procedures was directly observed and documented by surveyors during the provision of care.