Failure to Perform Hand Hygiene Between Resident Care Activities
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program for two residents who required assistance with personal care. Direct observation revealed that a medical assistant (MA) did not perform hand hygiene after providing care to one resident and before providing care to another. Specifically, the MA removed a blood pressure cuff from the first resident, exited the room without washing hands or using hand sanitizer, and then entered the second resident's room and removed a blood pressure cuff from that resident, again without performing hand hygiene before or after contact. Both residents involved had significant medical histories and were at increased risk for infection. One resident had a urinary catheter, surgical incisions, and wounds, with care plans and physician orders indicating the need for enhanced barrier precautions and close monitoring for infection. The other resident had multiple chronic conditions, including diabetes and cognitive impairment, with care plans highlighting the risk for infection and the need for monitoring and reporting signs of infection. The facility's own policies required staff to perform hand hygiene before and after resident contact and when moving between resident rooms, in accordance with accepted standards of practice. Despite these policies, the observed failure to perform hand hygiene between resident care activities constituted a breach of infection control protocols, as confirmed by staff interviews and review of facility policies.