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F0880
D

Failure to Perform Hand Hygiene After PPE Removal in Isolation Rooms

Colton, California Survey Completed on 07-09-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

A Certified Nursing Assistant (CNA) failed to perform hand hygiene after removing personal protective equipment (PPE) upon exiting the isolation rooms of two residents who were on contact precautions for multidrug-resistant organisms (MDROs). During an observation, the CNA was seen leaving the isolation room, doffing gloves and gown, but did not clean her hands afterward. The CNA explained that she did not perform hand hygiene because she believed she had not touched the resident or anything in the room. Review of the clinical records confirmed that both residents were on contact precautions due to MDROs. The Director of Nursing (DON) acknowledged that hand hygiene should have been performed after PPE removal. Facility policy and CDC guidelines both require hand hygiene as the final step after removing PPE to prevent the spread of infection.

See complete original report
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