Failure to Ensure Proper Hand Hygiene and PPE Use During Resident Care
Penalty
Summary
Staff failed to consistently perform proper hand hygiene and use appropriate personal protective equipment (PPE) as required by the facility's infection prevention and control program. Observations revealed that nurse aides exited a resident room under Enhanced Barrier Precautions (EBP) without completing hand hygiene and one aide was seen carrying a used glove in the hallway. The charge nurse also left the same room without performing hand hygiene. Interviews indicated a lack of awareness among staff regarding the requirements for EBP and the use of hand sanitizer, as well as confusion about the application of PPE for residents on precautions. In another instance, two nurse aides entered a room with a droplet precaution sign without donning any PPE, stating they believed it was unnecessary for simply delivering a meal, despite facility policy and leadership confirming PPE was required. Additionally, during a dressing change for a resident with lymphedema and neuropathy, an LPN failed to perform hand hygiene after removing gloves and before donning new gloves, and disposed of used gloves on the resident's bed rather than in a sanitary manner. Clean dressing supplies were placed on an overbed table alongside food items, and the LPN was unaware of the need for hand hygiene between glove changes. Interviews with facility leadership confirmed that hand hygiene should have been performed after glove removal, and facility policy directed staff to wash hands after removing gloves.