Failure to Maintain Infection Control Due to Improper Cleaning and Hand Hygiene
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program on one of its units, as evidenced by improper cleaning techniques and inadequate hand hygiene practices by housekeeping staff. During a continuous observation, a housekeeper was seen cleaning resident rooms and bathrooms without following established protocols. Specifically, the housekeeper did not remove residents' personal hygiene items from the bathroom counter before spraying disinfectant, failed to disinfect high-touch areas such as door knobs, bed remotes, call lights, light switches, over-bed tables, and night stands, and did not clean the bathroom door knob after touching it with soiled gloves. The housekeeper also used a wet rag from a bucket containing sanitizing solution to wipe down surfaces and handled cleaning equipment and room surfaces with the same gloves, increasing the risk of cross-contamination. Hand hygiene practices were not properly followed, as the housekeeper applied alcohol-based hand sanitizer and immediately donned gloves while her hands were still visibly wet, rather than allowing the sanitizer to dry as required. On several occasions, the housekeeper changed gloves without performing hand hygiene in between, and did not rub her hands with sanitizer until dry before putting on new gloves. These actions were inconsistent with both facility policy and CDC guidelines, which emphasize the importance of proper hand hygiene and thorough cleaning of high-touch surfaces to prevent the transmission of healthcare-associated infections. Interviews with the housekeeper revealed that she was primarily a laundry attendant and only occasionally worked as a housekeeper. She acknowledged receiving training on housekeeping and hand hygiene but admitted to forgetting to clean high-touch areas and not allowing her hands to dry after using hand sanitizer. The maintenance director was unaware of his responsibility for housekeeping oversight, and the regional clinical resource confirmed that staff were trained at hire and annually, reiterating the importance of proper cleaning and hand hygiene practices.