Failure to Follow Infection Control and Hand Hygiene Practices
Penalty
Summary
The facility failed to follow infection prevention and control practices, specifically in the areas of hand hygiene and the use of personal protective equipment (PPE) when entering and exiting resident rooms, including those on transmission-based precautions. Multiple staff members, including unit managers, nurses, the Director of Nursing, CNAs, a housekeeper, and a student volunteer, were observed entering rooms of residents on contact precautions for infections such as MRSA and VRE without donning the required PPE. In several instances, staff exited these rooms without performing hand hygiene. These lapses occurred despite clear signage and availability of PPE outside the rooms, and in contradiction to the facility's own policies and CDC guidelines for contact precautions. Residents involved included those with diagnoses of MRSA, VRE, and other infections requiring contact precautions. For example, one resident with MRSA in the nares and another with VRE in the urine had active physician orders and care plans indicating the need for contact precautions. Staff were observed disregarding these precautions, and interviews revealed inconsistent understanding among staff regarding the requirements for PPE use, with some staff incorrectly believing precautions were not necessary unless providing direct care. Additionally, the facility failed to ensure proper hand hygiene practices during meal service. Staff were observed serving meals to residents in both dining rooms and resident rooms without performing hand hygiene between residents or offering hand hygiene to residents prior to meals. This included staff handling trays, cutting food, and assisting residents with clothing protectors without cleaning their hands between tasks. Residents reported that they were not offered hand hygiene before meals, and some took it upon themselves to clean their hands. These practices were inconsistent with the facility's policy on employee hygiene and safe food handling.