Failure to Perform Hand Hygiene and Track Non-Antibiotic Illnesses
Penalty
Summary
The facility failed to ensure proper hand hygiene and glove changes during personal care for a resident with enhanced barrier precautions due to an indwelling catheter. During an observed care episode, a certified nursing assistant (CNA) donned gloves and a gown before entering the resident's room and proceeded to provide a range of personal care activities, including washing, dressing, pericare, and catheter care, without changing gloves or performing hand hygiene between tasks. The CNA also touched personal items, used a walkie talkie, and handled objects in the room while wearing the same gloves, only removing them at the end of the care episode. Interviews with the CNA and supervisory staff confirmed that gloves were not changed unless visibly soiled, and hand hygiene was not performed as required by facility policy and standard infection control practices. The resident involved had significant cognitive impairment and was dependent on staff for activities of daily living. The care plan specified the use of enhanced barrier precautions and outlined the need for staff to don and doff personal protective equipment appropriately and to perform hand hygiene during care. Despite these directives, the observed care did not follow the expected sequence of clean-to-dirty care, nor did it include necessary glove changes and hand hygiene at appropriate intervals, as confirmed by both the CNA and the director of nursing (DON) during interviews. Additionally, the facility did not have a system in place to track and trend symptoms of illness among residents who were not on antibiotics. Review of infection control logs revealed that only infections treated with antibiotics were recorded, with no documentation or tracking of viral, fungal, or other illnesses not requiring antibiotic therapy. The infection prevention and control policy referenced surveillance tools for recognizing infections and spotting trends, but did not address the need to track symptoms or illnesses that did not result in antibiotic use. Interviews with the DON confirmed that symptom tracking for potential infections not requiring antibiotics was not maintained in a spreadsheet or log, and infection logs were only completed for identified infections at the end of each month.