Failure to Follow Hand Hygiene and Infection Control Protocols
Penalty
Summary
Multiple staff members failed to follow proper hand hygiene and infection control protocols during meal service and while providing direct care. During meal distribution, staff including a CNA, Activity Director, and Activity Assistant did not sanitize their hands or don gloves before handling food or serving meal trays to residents. In one instance, a CNA removed a sandwich from its bag with bare hands and handed it to a resident without performing hand hygiene. Additionally, staff did not perform hand hygiene before donning gloves when entering a resident's room under enhanced barrier precautions, despite posted signage instructing them to do so. A Registered Nurse, while administering IV antibiotics to a resident with a midline IV access for a urinary tract infection, failed to change gloves or perform hand hygiene between tasks, and reused an alcohol wipe during the procedure. The facility's own hand hygiene policy requires hand hygiene before and after handling invasive devices and after contact with objects in the resident's immediate vicinity. These lapses were observed across multiple staff and residents, and were confirmed by staff interviews and review of facility policies.