Failure to Follow Infection Control and Hand Hygiene Protocols
Penalty
Summary
The facility failed to ensure staff compliance with infection prevention and control guidelines on two of three units, specifically regarding hand hygiene practices and the handling of soiled materials. Observations revealed that staff did not consistently perform hand hygiene before and after resident contact, after glove removal, or when handling potentially contaminated materials, as required by facility policy. For example, staff were seen using only hand sanitizer after providing care to a resident on enteric precautions for suspected Clostridium difficile (C. Diff), rather than washing hands with soap and water as recommended for C. Diff cases. Additionally, staff were observed carrying soiled linens down the hall without removing masks or performing appropriate hand hygiene, and clean PPE was stored in close proximity to soiled garbage cans, increasing the risk of cross-contamination. Resident 116, who was on enteric precautions for suspected C. Diff, received care from staff who did not follow proper infection control protocols. Staff wore PPE but used only hand sanitizer instead of washing hands after care, and did not remove masks upon exiting the room. Housekeeping staff also failed to perform hand hygiene between glove changes and were unclear about the requirements for enteric precautions, including whether a gown was necessary when handling soiled materials outside the resident's room. Multiple observations confirmed that clean PPE was stored adjacent to soiled waste, further violating infection control standards. For another resident, Resident 266, who was severely cognitively impaired, staff repeatedly failed to perform hand hygiene before entering the room, after providing perineal care, and after changing gloves. Staff assisted with personal care, dressing, and transfers without changing gloves or performing hand hygiene, despite acknowledging during interviews that these steps were required. These lapses in infection control practices were observed on multiple occasions and confirmed through staff interviews, indicating a pattern of non-compliance with established infection prevention protocols.