Failure to Perform Hand Hygiene Prior to Resident Transfer
Penalty
Summary
The facility failed to maintain an infection prevention and control program as required, specifically in the area of hand hygiene during resident care. On the observed date, CNA A assisted with a two-person gait belt transfer for a male resident with dementia, hypertension, generalized muscle weakness, and cognitive communication deficit, who required substantial to maximal assistance with activities of daily living. CNA A retrieved the resident's wheelchair from another room and did not perform hand hygiene before assisting with the transfer, despite having sanitized hands prior to entering the room initially. This lapse was directly observed by surveyors during the transfer process. During interviews, CNA A acknowledged the failure to perform hand hygiene before the transfer and recognized the expectation to do so. The Director of Nursing (DON) confirmed that staff are expected to wash or sanitize hands prior to resident transfers, as outlined in the facility's hand hygiene policy. The policy, implemented in June 2025, requires all staff to perform proper hand hygiene before performing resident care procedures to prevent the spread of infection.