Failure to Provide Hand Hygiene and Properly Label Bath Basins
Penalty
Summary
Staff failed to assist or offer hand hygiene to four residents before and/or after meals, as observed during multiple meal times. These residents had varying degrees of cognitive impairment and physical limitations, including sequelae of cerebral infarction, spinal stenosis, dementia, diabetes, hemiplegia, traumatic brain injury, muscle wasting, and atrophy. Observations confirmed that staff did not provide or prompt hand hygiene for these residents during meal service. Additionally, bath basins used by three residents were found uncovered and unlabeled under shared vanity sinks. The Director of Nursing confirmed that facility procedure requires basins to be labeled and covered with plastic, and that staff are expected to assist residents with hand hygiene before and after meals. These lapses were directly observed and confirmed through staff interview.