Failure to Follow Proper PPE Removal and Hand Hygiene Procedures
Penalty
Summary
Multiple staff members failed to follow proper infection prevention and control practices, specifically regarding the removal of personal protective equipment (PPE) and hand hygiene. Observations showed that staff, including CNAs and an RN, exited contact isolation rooms without removing used gowns and gloves inside the room as required. In some cases, used PPE was disposed of in bins located outside the resident rooms, contrary to facility policy and CDC guidelines. Staff interviews revealed a lack of consistent understanding and adherence to the correct procedures for PPE removal, with some staff admitting to habitual non-compliance or being unaware of the proper process. Further deficiencies were observed in hand hygiene practices among staff. Housekeeping and nursing staff were seen changing gloves between tasks or after leaving resident rooms without performing hand hygiene in between glove changes. Staff interviews confirmed that some were unaware of the requirement to clean hands before donning new gloves, while others acknowledged the expectation but failed to comply during observed instances. These lapses occurred during routine care activities, such as meal delivery, medication administration, and cleaning resident rooms. The facility's own policies, updated in June 2024, require adherence to CDC hand hygiene and PPE guidelines, which specify that PPE must be removed and hand hygiene performed before leaving a resident's environment. Despite these policies, observations and staff statements demonstrated inconsistent implementation, resulting in a failure to maintain effective infection prevention and control for residents, staff, and visitors.