Failure to Ensure Consistent Hand Hygiene and Enhanced Barrier Precautions
Penalty
Summary
Staff failed to consistently perform hand hygiene when providing meal assistance to residents. During a lunch meal observation, a CNA used alcohol-based hand rub (ABHR) before assisting residents but subsequently touched her nose, picked up a pen from the floor, and continued to assist residents without reapplying ABHR. The CNA also picked up an ABHR cap from the floor and then assisted a resident with her beverage without performing hand hygiene. Another CNA provided meal assistance to two residents without performing hand hygiene between assisting each resident. Both CNAs acknowledged in interviews that hand hygiene should be performed before and between assisting residents, but one CNA reported not having ABHR available due to supply shortages. The facility's infection prevention and control program policy requires staff to adhere to hand hygiene practices to prevent the spread of infections. However, observations revealed that staff did not consistently follow these practices, particularly during meal assistance. Staff interviews indicated gaps in knowledge and inconsistent access to hand hygiene supplies, with one CNA stating her ABHR was in her backpack and the supply cabinet was empty. The infection preventionist (IP) and director of nursing (DON) confirmed that hand hygiene training was provided at hire and during outbreaks, but could not specify when the last training occurred, and the clinical consultant could not find recent training records related to hand hygiene during meal assistance. Additionally, the facility failed to ensure the use of enhanced barrier precautions (EBP) and appropriate personal protective equipment (PPE) for residents with conditions such as urinary catheters and pressure ulcers. Multiple observations showed that rooms of residents requiring EBP lacked PPE supplies, and staff did not don PPE when providing direct care. Staff interviews revealed a lack of awareness regarding EBP requirements, with some staff believing only gloves were necessary for residents with catheters or pressure ulcers. The infection preventionist stated that residents with these conditions should be on EBP and that staff should use gloves and gowns, but this was not consistently implemented.