Failure to Follow Hand Hygiene Protocol for C. difficile Infection
Penalty
Summary
The facility failed to follow its infection control policy regarding hand hygiene for residents with Clostridium difficile (C. difficile) infection. Specifically, two nursing assistants and a medication aide used alcohol-based hand sanitizer instead of washing their hands with soap and water after providing care to a resident with an active C. difficile infection. The facility's policy, as well as the enteric precaution signage, required staff to wash hands with soap and water because alcohol-based hand sanitizers are not effective against C. difficile spores. Interviews revealed that the staff members were unaware of this requirement and routinely used hand sanitizer after care, regardless of whether there was contact with stool. The deficiency was observed through record review and interviews with staff and a family member, who also reported never seeing staff wash their hands with soap and water after care. The resident involved had been admitted with a diagnosis of C. difficile and was on enteric precautions, including orders for personal protective equipment and specific antibiotic therapy. Despite the presence of appropriate signage and availability of PPE, staff did not adhere to the hand hygiene protocol outlined in the facility's infection control policy. The Director of Nursing confirmed that staff were expected to wash hands with soap and water after caring for residents with C. difficile, and that this was a facility policy. However, the interviewed staff, including agency personnel, were not aware that alcohol-based hand sanitizer was insufficient for C. difficile infection control.