Failure to Implement Proper Infection Control and Hand Hygiene Practices
Penalty
Summary
The facility failed to ensure proper infection prevention and control practices, specifically regarding hand hygiene and the use of personal protective equipment (PPE) for residents on Contact Precautions. Staff were observed entering and exiting rooms of residents on Contact Precautions without donning appropriate PPE or performing hand hygiene, despite clear signage and facility policy. In one instance, a CNA entered a resident's room twice without PPE and did not perform hand hygiene upon exit. In another case, an LPN entered a resident's room without PPE, used a reusable blood pressure device without cleaning it afterward, and placed it on a medication cart without a barrier. Both staff members acknowledged their failure to follow proper procedures, and facility leadership confirmed that staff were confused about the differences between Enhanced Barrier Precautions and Contact Precautions. Additionally, during meal service in the main dining room, a CNA was observed wearing the same gloves while assisting multiple residents, handling food items, touching personal items such as a phone, and performing various tasks without changing gloves or performing hand hygiene between residents. The CNA admitted to only changing gloves and performing hand hygiene twice during meal service and recognized that hand hygiene should have been performed after touching personal items. Facility leadership confirmed that staff were expected to perform hand hygiene between assisting residents in the dining room.