Failure to Maintain Infection Control Program Due to Lapses in Hand Hygiene
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by multiple staff members not adhering to proper hand hygiene protocols during the provision of incontinence and wound care for two residents. Certified Nursing Assistants (CNAs) were observed providing incontinence care without performing hand hygiene before, during, or after the procedure. Specifically, one CNA donned gloves before washing hands, failed to perform hand hygiene after removing gloves, and continued care and handling of supplies without appropriate handwashing. This was confirmed during interviews, where the CNAs acknowledged forgetting to perform hand hygiene and recognized the expectation to do so before and between care tasks, as well as after glove removal. In another instance, two CNAs provided incontinence care to a resident with a stage 4 pressure ulcer and did not perform hand hygiene before donning gloves or after removing them. They also failed to cleanse the peri area as required and handled both soiled and clean items with the same gloves. The wound care nurse, RN, also failed to perform hand hygiene before donning gloves, did not disinfect the area where wound care supplies were placed, and did not change gloves or perform hand hygiene between dirty and clean tasks during wound care. The nurse placed soiled gauze on a clean bedsheet and did not have a designated area for contaminated materials. These actions were confirmed in interviews, where staff admitted to forgetting required hand hygiene steps and not following established protocols. Record reviews indicated that both residents involved had significant medical conditions, including severe cognitive impairment, incontinence, and, in one case, a stage 4 pressure ulcer. Facility policies required hand hygiene before and after resident contact, after contact with soiled items, and during wound care procedures. Despite these policies and reported staff training, the observed failures in hand hygiene and infection control practices were not in compliance with facility protocols. Training records requested by surveyors were not provided.