F0880

D

Failure to Perform Hand Hygiene Before Direct Resident Contact

Hawthorne, California Survey Completed on 02-17-2026

Penalty

No penalty information released

Summary

Surveyors identified a deficiency in infection prevention and control when a CNA entered a resident’s room and touched the resident’s forehead without performing hand hygiene. The resident had been admitted on 4/9/2022 and had diagnoses including dementia, Alzheimer’s disease, and dysphagia following a nontraumatic intracerebral hemorrhage, and a history and physical dated 1/2/2025 documented that the resident did not have the capacity to understand and make decisions. The resident’s orders included a fortified puree diet, pain assessments with pain management, and monitoring of both lower extremities every shift for redness, discoloration, swelling, and pain related to immobilizer use. During observation on 2/17/2026 at 11:19 a.m., the CNA touched the resident’s forehead without first cleaning their hands, and in a concurrent interview acknowledged they were supposed to perform hand hygiene before touching residents because not doing so could cause an infection. The facility’s hand hygiene policy dated 12/2023 required use of alcohol-based hand rub or soap and water before and after direct contact with residents.

This failure to perform hand hygiene before direct contact with the resident constituted noncompliance with the facility’s infection prevention and control program and its written hand hygiene policy.