Failure to Follow Hand Hygiene and Transmission-Based Precaution Protocols
Penalty
Summary
The deficiency involves the facility’s failure to ensure staff consistently followed hand hygiene protocols when entering and exiting resident rooms and after contact with resident environments. On one unit, a CNA entered a resident’s room, removed a breakfast tray, then went into another resident’s room, touched the bed and call light, exited, and proceeded directly into a third resident’s room without performing hand hygiene at any point. On another unit, a staff member entered a resident’s room, turned off the call light, and exited without using hand sanitizer or washing hands before or after room entry. A similar observation on a different hall showed another staff member entering and exiting a resident’s room without performing hand hygiene. These observations occurred despite staff interviews confirming their understanding that hand hygiene should be performed when entering and leaving resident rooms and before and after resident care or contact with resident belongings and surfaces. The deficiency also includes failure to follow posted Transmission-Based Precaution (TBP) signage and protocols. In one room with two female residents, two different precaution signs were posted on the door: one for Enhanced Barrier Precautions (EBP) and one for Contact Precautions, with the Contact Precaution sign specifying that gloves and gowns must be worn before entering and discarded before exiting. A RN assigned to the area stated he did not know which TBP posting applied to which resident and deferred to management for clarification. A CNA later stated that one sign was intended for the resident in bed A and the other for the resident in bed B, but he did not know why the residents were on precautions and believed the precautions did not apply, so he did not think the posted signs needed to be followed. Further observations showed that staff entered the same room with the two female residents to provide hygiene supplies without wearing any PPE and without performing hand hygiene prior to entry. Shortly afterward, another staff member also entered the room without PPE or hand hygiene. The RN subsequently removed both the EBP and Contact Precaution signs from the door and placed them on top of the isolation cart across from the room. The Infection Preventionist later stated that two residents with different TBP are not usually placed in the same room, that the stricter TBP should be followed if this occurs, that posted signs must be followed until confirmed otherwise, and that signs should not be removed without consulting her. The DON stated that staff were expected to follow TBP signage unless told otherwise, that nurses should know the TBP status and infection-related information for their assigned residents, and that staff must follow standard precautions, including hand hygiene and the most stringent TBP when there is conflicting information.
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