Failure to Follow Hand Hygiene and Transmission-Based Precaution Requirements
Penalty
Summary
The deficiency involves the facility’s failure to ensure staff followed its infection prevention and control policies, specifically related to hand hygiene and transmission-based precautions for residents on droplet and enhanced barrier precautions. The facility’s policy required that when a resident is placed on transmission-based precautions, appropriate signage be placed on the room entrance door to inform staff of the type of CDC precaution and instructions for PPE and hand hygiene. Resident 1 had a progress note indicating they were to be on contact precautions pending respiratory viral panel results, and a droplet precaution sign was posted on the room door instructing staff to clean their hands before entering and leaving the room. Residents 2 and 3 had physician orders and care plans for enhanced barrier precautions related to dialysis with a PEG tube and a Foley catheter, respectively, with signage on their shared room door requiring hand hygiene before entering and leaving. On one observation date, a nurse aide (Employee 3) was seen leaving the room of Residents 2 and 3, who were on enhanced barrier precautions, and entering Resident 1’s room, which was on droplet precautions, without performing hand hygiene between rooms, despite posted instructions. In Resident 1’s room, Employee 3 assisted the roommate, who was not on precautions, in the bathroom. On a subsequent observation, Employee 3 again entered Resident 1’s room without hand hygiene, donned gloves, removed the trash from that room, then entered the room of Residents 2 and 3 without changing gloves or performing hand hygiene, carrying the trash bag from Resident 1’s room into Residents 2 and 3’s room. Employee 3 then removed gloves and left without performing hand hygiene. During an interview, the Nursing Home Administrator stated she would have expected Employee 3 to perform appropriate hand hygiene before entering and leaving the residents’ rooms.
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