Failure to Maintain Infection Control: Hand Hygiene and Damaged Equipment
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program as evidenced by two main deficiencies. First, a licensed nurse did not perform hand hygiene between assisting two residents during a dining observation. One resident, with a history of hemiplegia and severely impaired cognition, was being assisted with eating by a nurse. Another resident, with dysphagia and moderately impaired cognition, was seated next to the first and began coughing. The nurse assisted the coughing resident by tapping his chest and then immediately returned to feeding the first resident, wiping his mouth without performing hand hygiene in between. The nurse later acknowledged that hand hygiene should have been performed between contacts. The DON confirmed that staff are expected to perform hand hygiene before and after resident contact to prevent infection, and the facility's policy also requires hand hygiene to prevent the spread of infection. Secondly, the facility did not ensure that bed rail padding was free of gouges and frayed areas for a resident who was non-verbal, unable to follow commands, and dependent on staff for all activities of daily living. During observation, the resident's bed rails were found to have a large gouge and multiple smaller gouges and frayed areas. A registered nurse confirmed that such damage to the padding prevents proper sanitation and could lead to infection, and stated that staff are required to report any integrity issues with bed rail padding so they can be replaced immediately. The administrator also stated that intact padding is designed to resist bacteria, but damaged padding must be replaced right away. The facility's policies require prompt reporting and replacement of damaged equipment and adherence to hand hygiene protocols. However, these procedures were not followed, as evidenced by the lack of hand hygiene between resident contacts and the failure to report and replace damaged bed rail padding. These actions and inactions resulted in deficiencies in the facility's infection prevention and control program.