Failure to Follow Infection Control and Hand Hygiene Protocols
Penalty
Summary
The facility failed to adhere to established infection prevention and control protocols during personal care activities for several residents. Observations revealed that certified nurse aides (CNAs) did not consistently perform hand hygiene after removing gloves, before applying new gloves, or before touching clean surfaces and equipment. In multiple instances, CNAs handled soiled items, then touched clean briefs, oxygen cannulas, clothing, and other surfaces without proper hand hygiene. For example, after providing perineal care and removing soiled gloves, CNAs applied new gloves or handled resident equipment without sanitizing their hands. Additionally, staff failed to disinfect reusable equipment, such as mechanical lifts, after use. In one case, a CNA exited a resident's room with a mechanical lift and placed it in the hallway without sanitizing it. Another CNA transported a resident to a lounge after care without performing hand hygiene upon exiting the room. These actions were not in accordance with the facility's infection prevention and hand hygiene policies, which require hand hygiene between resident contacts, after handling contaminated objects, and before and after glove use. The residents involved included individuals with specific care needs, such as a resident with a pressure ulcer and a history of skin breakdown. The observed deficiencies occurred during routine personal care activities, including perineal care, transfers using mechanical lifts, and handling of oxygen equipment. An administrative nurse confirmed that staff were expected to follow hand hygiene protocols and sanitize equipment as outlined in facility policy.