Infection Control Lapses in Hand Hygiene and PPE Use
Penalty
Summary
The facility failed to maintain an effective Infection Control Program as evidenced by multiple observed lapses in hand hygiene and improper use of personal protective equipment (PPE) by staff during medication administration, meal tray service, and while exiting transmission-based precaution areas. On one occasion, an LPN was observed rubbing his eyes and nose multiple times at the nurse's station and again while preparing and administering medications to a resident, all without performing hand hygiene. The LPN acknowledged that he should have performed hand hygiene, especially given his condition that causes frequent eye rubbing. During a lunch meal pass, two CNAs were observed turning and boosting a resident in bed, then exiting the room and immediately handling and delivering meal trays to other residents without performing hand hygiene. Both CNAs confirmed they should have performed hand hygiene after providing care and before handling food trays. Additionally, a Physical Therapy Assistant was seen exiting a unit wearing an isolation gown, walking through common areas, and only removing the gown in the dining room after being reminded, despite having just left a room where transmission-based precautions had been lifted. The staff member admitted to forgetting to remove the gown before leaving the resident's room.