Failure to Use Soap-and-Water Hand Hygiene for C. diff Contact Precautions
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control practices related to care of a resident with Clostridioides difficile (C. diff). The resident was admitted in February 2026 with diagnoses including enterocolitis due to C. diff and a urinary tract infection, and had physician orders for contact precautions, including use of gown and gloves when entering the room and ensuring proper hand hygiene before and after contact with the resident or their environment. The facility’s own C. diff policy directed frequent handwashing with soap and water by staff and residents, and the Infection Preventionist (IP) and Director of Nursing (DON) both stated that proper hand hygiene for C. diff required soap and water because alcohol-based hand gel would not kill C. diff bacteria. During observation on Hall 400, a CNA was seen entering the C. diff resident’s room wearing appropriate PPE. Upon exiting the room, the CNA removed PPE and performed hand hygiene using an alcohol-based sanitizing gel located outside the room, then immediately proceeded down the hall and entered another resident’s room. In a subsequent interview, the CNA confirmed using alcohol-based gel and stated she believed she had done appropriate hand hygiene before moving to the next resident, despite the resident’s known C. diff infection. The IP and DON both indicated their expectation that staff wash hands with soap and water after caring for a C. diff resident, and the DON stated the risk was the spread of infection to other residents. CDC guidance cited in the record indicated that washing hands with soap and water is the best way to prevent the spread of C. diff from person to person.
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