Failure to Adhere to Hand Hygiene Protocols
Summary
Staff failed to consistently offer or perform hand hygiene (HH) for residents after meals, as observed with multiple residents who were not provided HH following lunch. Interviews with staff confirmed that facility policy requires offering HH before and after meals for infection control, and staff acknowledged not following this policy during the observed incidents. The nurse manager also confirmed that HH should be offered to residents before and after meals to prevent infection. Additionally, staff did not perform HH prior to preparing medications or before and after donning gloves, as observed with a licensed psych technician during medication pass and glove use. Staff interviews confirmed awareness of the facility's policy to perform HH in these situations, and the facility's written policy also requires HH before and after eating, before preparing medications, and after removing gloves. These lapses were directly observed and verified by staff and the nurse manager during interviews.
Plan Of Correction
On 4/7/25-4/10/25, all staff were in-serviced on Hand Washing/Hand Hygiene Policy and Procedure (P&P) by the Director of Nursing (DON), Director of Staff Development (DSD), Assistant Director of Staff Development (ADSD), and Infection Preventionist (IP). The training included: 1) Offering Hand Hygiene (HH) to residents after meals 2) Utilizing HH prior to preparation of medications 3) Utilizing HH prior to donning and doffing of gloves The IP, DSD, and ADSD will observe and monitor: (1) Staff offering HH to residents after meals (2) Utilizing HH prior to preparation of medications (3) Utilizing HH prior to donning and doffing of gloves Audits will be conducted three times a week for 3 weeks, twice weekly for 2 weeks, and then once weekly for 1 week. Additionally, random audits will be performed for one month. System effectiveness will be evaluated during the facility's monthly Quality Assurance Performance Improvement Committee for three months.
Penalty
Surveyors found that a resident with COVID-19 did not have the required droplet precaution signage posted, another resident receiving IV antibiotics lacked enhanced barrier precaution signage and supplies, and two nurses failed to perform hand hygiene before administering medications, with one also not wearing gloves for eye drop administration. These actions were inconsistent with the facility's infection control policies.
Infection Control Lapses in Signage, Precautions, and Hand Hygiene
Penalty
Summary
Surveyors identified multiple deficiencies in the facility's infection control practices. In one instance, a patient with a confirmed diagnosis of COVID-19 was not properly identified with a droplet transmission-based precaution sign outside her room. Although the patient's care plan required standard, contact, and droplet isolation with eye protection and a closed door, only an enhanced barrier precaution sign was posted. The Assistant Director of Nursing and the Infection Preventionist both acknowledged that the correct signage was not in place, which could have led to unintentional exposure of staff, visitors, and other patients to COVID-19. Another deficiency was observed with a patient who had a surgical site infection and was receiving intravenous antibiotics. Despite facility policy requiring enhanced barrier precautions for residents with indwelling medical devices or wounds, there was no EBP sign or PPE supply cart outside the patient's room. Both the Director of Staff Development and the Director of Nursing confirmed that the appropriate signage and precautions were not implemented, contrary to facility policy and infection control standards. Additional lapses in infection control were noted during medication administration. Two nurses failed to perform hand hygiene before administering medications to two patients, and one nurse did not wear gloves while administering eye drops. The soap dispenser in one patient's room was also found to be empty. These actions were inconsistent with the facility's policies on hand hygiene, medication administration, and the instillation of eye drops, as confirmed by the Director of Nursing and review of facility procedures.
Plan Of Correction
The DON/Designee will report daily findings of Room Rounds to the QAPI/QAA committee monthly for three months for recommendations, if any. E) COMPLETION DATE: 10/31/2025 C 1270- Nursing Service - Patients with Infectious Disease A) IMMEDIATE CORRECTIVE ACTION: 1. On 10/06/2025, facility Infection Preventionist (IP) immediately replaced the door signage with the appropriate Droplet Precautions signage on patient 1's door to reflect the appropriate isolation precautions. All assigned staff who worked in patient 1's room were tested with a Rapid Antigen Test - all results were negative, and staff were notified to test again on days 3 and 5 and monitor themselves for any signs or symptoms of possible Covid-19. To date, no additional staff have tested positive for Covid-19, and the facility outbreak has been closed. 2. On 10/6/2025, upon identification of deficient practice, CNA 6 immediately donned the correct PPE, and IP immediately placed an EBP sign on the door of patient 6. CNA was immediately provided with a one-on-one in-service by the DSD on Enhanced Barrier Precautions. RN Supervisor immediately assessed patient 6 for any change of condition (COC) or adverse reactions that may have been caused by the deficient practice. No COC noted. MD and RP were notified. 3. On 10/7/2025, LVN 5 immediately completed the required hand hygiene protocols upon the identification of deficient practice. RN Supervisor immediately assessed patient 11 for any change of condition (COC) or adverse reactions that may have been caused by the deficient practice. No COC noted. MD and RP were notified. DON immediately completed a one-on-one in-service with LVN 5 on the importance of hand hygiene and hand hygiene protocols during medication administration. 4. On 10/7/2025, LVN 4 immediately completed the required hand hygiene protocols upon the identification of deficient practice. RN Supervisor immediately assessed patient 9 for any change of condition (COC) or adverse reactions that may have been caused by the deficient practice. No COC noted. MD and RP were notified. DON immediately completed a one-on-one in-service with LVN 4 on the importance of hand hygiene and hand hygiene protocols during medication administration. B) HOW FACILITY WILL IDENTIFY OTHER RESIDENTS HAVING THE POTENTIAL TO BE AFFECTED BY THE DEFICIENT PRACTICE: 1. On 10/6/2025, upon identification of deficient practice, DON, ADON, and DSD immediately rounded the facility to ensure that all other isolation signage has been posted appropriately and corresponded with the ordered isolation precautions. No additional deficient practices were identified. 2. On 10/6/2025, upon identification of deficient practice, DON, ADON, and DSD immediately rounded the facility to ensure that all other staff providing care to residents on EBP were donning appropriate PPE when providing care. No additional deficient practices were identified. 3. & 4. On 10/7/2025, upon identification of deficient practice, DON, ADON, and IP immediately rounded the facility to ensure that all other charge nurses are completing hand hygiene timely and appropriately during medication administration. No additional deficient practices were identified. C) MEASURES PUT IN PLACE TO ENSURE THAT THE DEFICIENT PRACTICE DOES NOT OCCUR: 1. On 10/14/2025, clinical resource consultant completed a one-on-one in-service for the IP on Standard, Enhanced, and Transmission-based Precautions, hand hygiene, PPE use, L.A. County DPH - IPCP Guidelines for SNFs, EBP program, and assessment of all residents for EBP eligibility. 2.-4. On 10/20/2025, DSD completed an in-service for all nursing staff on infection control and types of isolations, EBP, donning and doffing PPE, and hand hygiene. On 10/28/2025, DON completed an in-service for all nursing staff on infection control and types of isolations and signage, EBP, and hand hygiene during medication administration. The discussion was followed by a question-and-answer evaluation. 3. Effective 10/30/2025, IP and/or designee will monitor EBP and other isolation signage during daily facility rounds and document performance on surveillance checklist. 4. Effective 10/30/2025, facility implemented a medication pass audit that will be completed weekly at random by the DON, ADON, and/or designee to monitor charge nurses' medication administration performance on proper and accurate medication administration and hand hygiene. Any noted deviations will be corrected immediately, and continued mentoring and performance improvement plans will be implemented as needed. D) HOW THE FACILITY PLANS TO MONITOR ITS PERFORMANCE TO MAKE SURE THAT SOLUTIONS ARE SUSTAINED: The IP/Designee will report Infection Control Surveillance results to the QAPI/QAA committee monthly for three months for recommendations, if any. DON/Designee will report weekly medication pass audits to the QAPI/QAA committee monthly for three months for recommendations, if any. E) COMPLETION DATE: 10/31/2025
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