F0880

E

Failure to Disinfect Equipment and Perform Hand Hygiene During Resident Care

Plano, Texas Survey Completed on 02-03-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to maintain an effective infection prevention and control program, including proper disinfection of reusable equipment and adherence to hand hygiene practices. A male resident with hypertension and anemia, cognitively intact with a BIMS score of 14, had his blood pressure taken by a medical assistant (MA A) using a blood pressure cuff that had just been removed from the assistant’s own wrist. The assistant did not disinfect the cuff before entering the resident’s room and applying it. In interview, the assistant acknowledged she was supposed to use disinfectant wipes to clean the cuff after removing it from her wrist and before applying it to the resident, and stated she had received training on care and disinfection of reusable equipment but could not recall when.

The deficiency also includes failures in hand hygiene during incontinence care for two residents with bowel and bladder care needs. One female resident with severe cognitive impairment (BIMS score of 7), hypertension, and diabetes had a care plan identifying risk for bowel and bladder elimination problems and directing peri care after each incontinent episode. A CNA (CNA B) entered this resident’s room to provide incontinence care, put on gloves without washing hands, and cleansed the resident’s abdominal folds and perineal area using wet wipes. After removing a soiled brief, the CNA did not perform hand hygiene or change gloves before applying a clean brief and repositioning the resident. The CNA later stated she knew she was supposed to perform hand hygiene before resident contact, between care, and after glove removal, but said she forgot, and acknowledged that failure to do so could lead to contamination and spread of infection.

A third resident, a male with severe cognitive impairment (BIMS score of 0) and hypertension, had a care plan focused on bowel and bladder with interventions to check, change, and keep him clean and dry. During observed incontinence care, another CNA (CNA C) prepared supplies, entered the room, and donned gloves without washing hands. The CNA cleansed the resident’s abdominal area, penis, and Foley catheter, then turned the resident, cleansed the buttocks after a bowel movement, and changed gloves between care without performing hand hygiene. After the resident was clean, the CNA again removed gloves and put on new gloves without hand hygiene before applying a clean brief and cream, and only washed hands after removing gloves at the end of care. In interview, this CNA stated he was supposed to perform hand hygiene before contact and with each glove change, but forgot, and acknowledged that failure to perform hand hygiene during incontinence care could lead to cross contamination and infection. The DON stated her expectation that staff perform hand hygiene before resident contact, between care, and with glove changes, and that reusable equipment be disinfected before and after use, and training records showed the involved staff had not attended prior in-services on these topics.