Failure to Follow Infection Control and Hand Hygiene Procedures
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by staff not following proper hand hygiene and infection control procedures during resident care. In one instance, a CNA entered a resident's room carrying soiled linen and trash from another room, removed her gloves, and did not wash her hands before providing care. The CNA acknowledged that she should have discarded the soiled items and gloves before entering another room and should have performed hand hygiene before and after resident contact. Facility leadership and the CNA both confirmed that these actions were not in line with facility policy and posed a risk of cross-contamination. In another case, an LVN was observed entering a resident's room, picking up gloves that had fallen on the floor, and then donning them to provide care, including administering water and checking blood sugar. The LVN did not discard the contaminated gloves or perform hand hygiene before or after providing care. The LVN later stated that the correct procedure would have been to discard gloves that fell on the floor and to wash hands before and after resident contact. The resident involved had multiple diagnoses, including dementia, diabetes, and mobility issues, and required regular blood sugar checks and assistance with care. Interviews with staff and facility leadership confirmed that the expectation was for all staff to follow hand hygiene protocols and not to use contaminated PPE. Facility policy required hand hygiene before and after resident contact and proper handling of soiled linen. The observed failures by both the CNA and LVN to adhere to these protocols resulted in a deficiency related to infection prevention and control for the residents involved.