Failure to Implement Hand Hygiene Practices During Resident Care
Penalty
Summary
The facility failed to implement its infection prevention and control program as outlined in its policies and procedures, specifically regarding hand hygiene practices among staff during resident care. Certified Nursing Assistants (CNAs) were observed assisting multiple residents with meals without performing hand hygiene between residents. For example, one CNA assisted two residents with feeding at the same time, touching their bibs, and did not perform hand hygiene between assisting each resident. Similar observations were made with other CNAs who also failed to perform hand hygiene between assisting different residents during mealtime. Additionally, a Licensed Vocational Nurse (LVN) was observed administering oral medications to a resident, then preparing and administering a nebulizer treatment without performing hand hygiene between the two different routes of medication administration. The LVN handled the resident's bed controls and nebulizer equipment after administering oral medications, contrary to the facility's policy which requires hand hygiene before preparing and handling medications and after contact with objects in the resident's immediate vicinity. Interviews with the involved staff confirmed that hand hygiene was not performed as required by facility policy. The Director of Staff Development (DSD) and Director of Nursing (DON) both acknowledged that staff are expected to perform hand hygiene before and after assisting residents with meals and between different medication administration routes, but these practices were not followed during the observed incidents.