F0880

E

Failure to Follow Hand Hygiene, PPE, and Meal-Time Infection Control Practices

Watertown, Wisconsin Survey Completed on 03-12-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to implement and maintain its infection prevention and control and hand hygiene policies, including during enhanced barrier precautions, contact precautions, medication administration, and meal service. The facility’s policies required hand hygiene before and after resident contact, after glove removal, when moving from soiled to clean body sites, and before medication preparation and administration. Policies also required appropriate use of PPE for residents on contact precautions and mandated that all residents be offered hand hygiene prior to meals. Surveyors found multiple instances where these requirements were not followed.

One resident on enhanced barrier precautions due to a catheter and a wound was observed receiving peri care and catheter care from a CNA who did not change gloves or perform hand hygiene when moving from dirty to clean tasks. The CNA washed the resident’s upper body, anterior peri area, and completed catheter care without removing soiled gloves, cleansing hands, and donning clean gloves before touching the resident’s gown. The CNA then removed soiled gloves, retrieved a bottle of hand sanitizer from under the gown and reached into the scrub top without performing hand hygiene, and later washed the resident’s peri rectal area without changing gloves or cleansing hands. The CNA also touched the resident and a bottle of lotion before finally removing gloves, cleansing hands, and donning clean gloves. The DON, present for most of the observation, confirmed that staff should remove soiled gloves, cleanse hands, and don clean gloves when going from dirty to clean, and the CNA did not understand the breach in hand hygiene.

Another resident with a history of carbapenem-resistant Acinetobacter baumannii (CRAB) and open wounds had an active order for contact isolation and a contact precautions sign posted at the room. Despite the sign instructing everyone to clean their hands before entering and when leaving, and for staff to don and discard gloves and gowns upon room entry and exit, the assistant administrator entered the room without performing hand hygiene or donning PPE, then exited and entered another room without hand hygiene. When questioned, the assistant administrator stated that if the sign was not on the resident’s door it was not active, and only after the RN checked the electronic record and confirmed the resident was on precautions for CRAB did the assistant administrator acknowledge that appropriate precautions should have been followed.

Surveyors also observed a RN preparing and administering medications to multiple residents without performing hand hygiene at the start of medication preparation or before administering medications, contrary to the facility’s medication administration policy. The RN later stated that hand hygiene was usually completed between every several residents unless there were visible bodily fluids, while the DON indicated staff should complete hand hygiene prior to medication preparation and after medication administration. In addition, during multiple meal services on different units and in the main dining room, residents were not offered hand hygiene before eating. Trays did not include hand hygiene wipes, tables lacked wipes or hand sanitizer, and staff did not offer hand hygiene prior to meals. A CNA acknowledged not offering hand hygiene before breakfast and described only using a wet paper towel if hands were dirty after meals. Two residents reported they were not offered hand hygiene before or after meals but stated they would like or thought it would be a good idea to be offered hand hygiene. The dietary manager and nursing leadership confirmed that residents should be offered hand hygiene prior to meals and that hand wipes should be on room trays for all meals.