Failure to Perform Proper Hand Hygiene During Resident Care
Penalty
Summary
Surveyors identified that the facility failed to implement and maintain an effective infection prevention and control program, specifically regarding hand hygiene practices during wound care and medication administration. Staff did not consistently perform hand hygiene as required by facility policy and accepted standards of practice. The facility's own policies state that hand hygiene must be performed after removing gloves and before donning new gloves, as well as after handling contaminated items or performing procedures such as wound care and blood glucose testing. In multiple observed instances, a nurse practitioner performed wound care on two residents with pressure ulcers and failed to perform hand hygiene after removing gloves and before putting on new gloves, despite handling wounds and dressings. The nurse practitioner stated that she only washes hands when leaving the resident's room and believed that removing gloves was sufficient to remove contamination. The Director of Nursing confirmed that hand hygiene should have been performed after glove removal and before donning new gloves, in accordance with facility policy. Additional observations included a LPN performing a blood glucose test and then touching the medication cart without removing gloves or performing hand hygiene, as well as another LPN failing to remove gloves and cleanse hands after removing a wound dressing and before cleansing the wound. This LPN also touched the outside of a contaminated gown with bare hands during PPE removal. Interviews with staff and the Director of Nursing confirmed that these actions were not consistent with facility policy or infection control standards.