Failure to Perform Hand Hygiene Before Resident Feeding
Penalty
Summary
Facility staff failed to perform required hand hygiene while providing care to one of seven sampled residents, resulting in a deficiency in the infection prevention and control program. During a tour, CNA 3 was observed assisting a resident in a shared room by using the bed remote, placing the remote on the floor, then picking it up and placing it on the resident’s bed without cleaning it. CNA 3 then proceeded to feed the resident without performing hand hygiene. In a concurrent interview, CNA 3 acknowledged not performing hand hygiene and stated that infection prevention and hand hygiene are important because they prevent residents from harm. In the same room, CNA 4 was observed entering from the hallway and approaching to feed the same resident without performing hand hygiene. In a concurrent interview, CNA 4 acknowledged not practicing hand hygiene and stated that hand hygiene is very important to keep residents safe because they are weak and can easily get sick. Record review showed the resident had diagnoses including anoxic brain damage, UTI, a disorder involving the immune mechanism, and heart failure, and was cognitively impaired and dependent on staff for substantial/maximal assistance with eating and personal hygiene. The ADON stated that all staff are trained and expected to perform hand hygiene before and after resident care, and the IP stated that hand hygiene is a standard precaution and agreed that staff were supposed to perform hand hygiene before feeding a resident. The facility’s Infection Prevention and Control Program policy indicated that infection prevention includes educating staff and ensuring adherence to proper techniques and following CDC guidelines.
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