Failure to Maintain Functional Soap Dispensers and Ensure Hand Hygiene Compliance
Penalty
Summary
The facility failed to ensure consistent hand hygiene practices in accordance with accepted standards, specifically by not maintaining functional soap dispensers in multiple resident rooms. During a facility tour, it was observed that several rooms lacked working soap dispensers, and in one case, the dispenser was missing entirely. This issue affected residents in the south hallway, as their bathrooms did not have the necessary supplies for proper hand hygiene. The Director of Nursing (DON) and Administrator confirmed that they were unaware of the non-functional dispensers, as staff had not reported the issue. Further observations revealed that staff did not use the hallway alcohol sanitizer before entering or after exiting resident rooms, and it was unclear how hand hygiene was being performed in rooms without functional soap dispensers. The DON was unable to verify staff compliance with hand hygiene protocols in the affected area and stated that audits and education had not previously identified any issues. Review of the facility's policy indicated that alcohol-based hand rub should be accessible in every resident room, but this standard was not met in the identified cases.