Failure to Ensure Proper Hand Hygiene During Resident Care
Penalty
Summary
The facility failed to maintain an effective Infection Prevention and Control Program, as evidenced by multiple instances of staff not performing proper hand hygiene during resident care. Certified Nursing Assistants (CNAs) and Licensed Vocational Nurses (LVNs) were observed providing incontinent care and other direct resident contact without changing gloves or performing hand hygiene when moving from contaminated to clean areas. For example, during incontinent care for a male resident with multiple diagnoses including heart failure, dementia, and a stage IV pressure ulcer, a CNA did not change gloves or perform hand hygiene before handling a clean brief, despite having contaminated gloves. The CNA later acknowledged the lapse, attributing it to the absence of visible contamination on the gloves. In another instance, a CNA and an LVN provided incontinent care to a male resident with cerebrovascular disease and hemiplegia, touching clean items such as briefs, linens, and a bedside remote with contaminated gloves before eventually removing gloves and performing hand hygiene. Both staff members admitted to not following proper hand hygiene protocols during the care episode. Additionally, an LVN was observed entering a resident's room and making direct contact with the resident's mouth and secretions without performing hand hygiene after using the computer at the nurse's station. The LVN acknowledged the failure to perform hand hygiene but did not provide a reason for the omission. Further observations revealed an LVN repeatedly failed to perform hand hygiene before donning gloves and making contact with three different residents after handling items such as the facility computer, medication cart, and keys. The LVN did not consider hand hygiene necessary before resident contact in these situations. Facility leadership, including the Assistant Director of Nursing (ADON), Director of Nursing (DON), and Administrator, all stated that their expectation was for staff to perform hand hygiene prior to donning gloves and before any resident contact, in accordance with facility policy. The facility's hand hygiene policy requires staff to wash hands after removing gloves, between resident contact, after handling contaminated objects, and before performing resident care procedures.