Failure to Perform Proper Hand Hygiene During Resident Care
Penalty
Summary
The facility failed to ensure proper hand hygiene practices were followed by staff during personal care for four residents. Observations revealed that nursing assistants did not consistently perform hand hygiene between glove changes or after removing gloves, particularly during perineal care and when cleaning residents after bowel movements. In several instances, staff used the same gloves or cleaning utensils to clean both the front and back perineal areas, and in some cases, failed to sanitize or wash hands before donning new gloves or after completing care tasks. Residents involved had significant care needs, including assistance with hygiene due to conditions such as fractures, intellectual disabilities, and parkinsonism. Staff were observed providing extensive assistance, including the use of mechanical lifts and enhanced barrier precautions. Despite these measures, lapses in infection control were noted, such as using contaminated washcloths, not changing gloves between different care tasks, and not performing hand hygiene at appropriate times during and after care. Interviews with staff indicated inconsistent understanding and application of hand hygiene protocols. Some staff believed handwashing was only necessary between residents or after particularly messy care, while others were unaware of the need to perform hand hygiene between glove changes. Facility leadership acknowledged the importance of proper hand hygiene and recognized that current practices did not meet expected standards, as confirmed by the facility's own infection prevention policies.