Failure to Follow Infection Control and Hand Hygiene Protocols
Penalty
Summary
The facility failed to maintain proper infection prevention and control practices for multiple residents and staff, as evidenced by direct observations, interviews, and record reviews. One incident involved a female resident with severe cognitive impairment and total dependence on staff for toileting hygiene, who required an indwelling catheter and was always incontinent of bowel. During incontinent care, a CNA removed soiled gloves and applied clean gloves without performing hand hygiene, then continued to provide care and adjust the resident's linens and bed with soiled gloves. The CNA acknowledged awareness of the correct procedure but did not follow it during the observed care. Additional deficiencies were observed during meal tray distribution and resident care. One CNA passed trays to all residents on a hall without sanitizing her hands between residents, despite having direct contact with residents and their personal items. Another CNA was observed leaving a resident's room with gloves on, retrieving a clean gown from a linen cart, and returning to the room to continue care and set up a meal tray, all without removing or changing gloves or performing hand hygiene. Both CNAs admitted to knowing the correct protocols but failed to follow them, citing being rushed or forgetting. Further, another CNA was observed passing and setting up meal trays for multiple residents and feeding a resident without performing hand hygiene between tasks. Interviews with staff and leadership confirmed that hand hygiene is expected before and after resident contact, between tasks, and before feeding residents. Facility policies reviewed also required hand hygiene at these critical points, but these procedures were not consistently followed by staff during the survey period.