Failure to Follow Infection Control and Hand Hygiene Protocols
Penalty
Summary
Multiple staff members failed to follow established infection prevention and control protocols during the provision of care to several residents. In one instance, a certified nursing assistant (CNA) provided incontinent care to a resident with severe cognitive impairment without performing hand hygiene before donning gloves, used the same gloves throughout the care process—including when handling clean supplies—and did not change gloves when moving from dirty to clean tasks. The CNA also failed to wash or sanitize hands after removing gloves and leaving the resident's room. The resident was dependent on staff for activities of daily living due to diagnoses including metabolic encephalopathy and dementia. Another CNA assisted a resident with Parkinson's disease and diabetes in the restroom without washing hands before putting on gloves or after removing them, leaving the resident's room without performing hand hygiene. A third CNA, while providing incontinent care to a resident with a urinary tract infection and diabetes, used gloves taken from her uniform pocket, did not perform hand hygiene before or after care, and used the same gloves to both clean the resident and handle clean wipes. This CNA also left the resident's room to retrieve supplies without washing hands and continued care upon return without hand hygiene, further contributing to cross-contamination risks. Additional infection control lapses were observed, including staff leaving untied plastic bags containing soiled items and used gloves on the floor outside resident rooms, and transporting clean linens on a wheelchair without using protective bags. Staff interviews confirmed awareness of proper infection control procedures, such as hand hygiene before and after resident care, not using gloves from uniform pockets, and proper disposal of soiled items, but these protocols were not consistently followed during observed care activities.