Failure to Perform Hand Hygiene Between Glove Changes During Catheter Care
Penalty
Summary
Unit Manager #2 failed to follow the facility's Handwashing/Hand Hygiene policy while providing suprapubic catheter care to Resident #83. During the procedure, after cleaning the catheter site and removing her gloves, Unit Manager #2 did not perform hand hygiene before donning a new pair of gloves to apply a dressing. This action was observed directly by surveyors, and the facility's policy specifically requires hand hygiene after glove removal and before donning clean gloves for aseptic tasks. Resident #83 had a suprapubic catheter with a slightly reddened area at the insertion site, which was being cleaned and dressed by Unit Manager #2. The failure to perform hand hygiene occurred after the initial cleaning and before the application of a new dressing. Both the Infection Preventionist and the Director of Nursing confirmed in interviews that the expected procedure was not followed, and Unit Manager #2 acknowledged the oversight during her interview.