Failure to Ensure Proper Hand Hygiene Prior to Resident Transfer
Penalty
Summary
A certified nursing assistant (CNA) failed to perform proper hand hygiene prior to assisting a resident with a transfer from bed to wheelchair. During observation, the CNA was seen lathering her hands for only approximately 6 seconds, which is less than the facility's policy requirement of at least 15 seconds and the generally accepted standard of 20 seconds. The CNA later stated in an interview that she believed she had washed her hands for 20 seconds or more and acknowledged that handwashing should be performed for 20 seconds to prevent cross contamination. The last hands-on in-service training for handwashing was conducted in September 2025, and the CNA had participated without reported issues at that time. The resident involved was an elderly female with a history of arteriovenous malformation of cerebral vessels, cerebral infarction, hypertension, and COPD. She had moderate cognitive impairment and required substantial to maximal assistance for transfers. Both the Director of Nursing (DON) and the Assistant Director of Nursing (ADON), who also served as the Infection Preventionist, confirmed in interviews that staff are expected to scrub their hands for at least 20 seconds to prevent cross contamination and reduce infection risk. The facility's hand hygiene policy, last reviewed in August 2019, specifies that hands should be rubbed together vigorously for at least 15 seconds, covering all surfaces.