F0880

E

Failure to Implement Hand Hygiene and Contact Precaution Practices

Washington, District Of Columbia Survey Completed on 02-04-2026

Penalty

No penalty information released

Summary

Facility staff failed to implement infection prevention and control practices related to contact and droplet precautions, hand hygiene, and availability of appropriate hand hygiene supplies. A resident with end stage renal disease, diastolic CHF, and moderate cognitive impairment was placed on contact isolation for bacterial conjunctivitis of the left eye, with a posted sign requiring droplet/contact precautions including hand hygiene on entry and exit, and use of gown, N95 respirator, eye protection, and gloves. While the unit manager stood outside this resident’s room and discussed the isolation status, a staff member was observed entering the room without performing hand hygiene or donning any PPE, later stating she was only going in to replace the resident’s water.

Additional observations showed that staff did not consistently perform hand hygiene and that required hand hygiene equipment was not functional or appropriate. During a dining observation, two staff members distributed and delivered meal trays without performing hand hygiene, and an alcohol-based hand rub station near the nurse’s station was found to be nonfunctional due to a broken handle. In a staff restroom on another unit, the wall-mounted hand soap dispenser was broken and nonfunctional, and staff were instead using a bottle of Sterex Medical Hospital bath and shampoo at the sink for handwashing. The infection preventionist confirmed that this product is used to bathe residents and is not acceptable for staff hand hygiene and was unsure how long the dispenser had been broken or how long staff had been using the shampoo for handwashing.