Failure to Follow Hand Hygiene Protocol During Incontinent Care
Penalty
Summary
A certified nursing assistant (CNA) failed to follow proper hand hygiene protocols while assisting with incontinent care for a female resident with dementia, a right hip fracture, macular degeneration, and hallucinations. The resident was severely cognitively impaired, required moderate assistance with activities of daily living, and was frequently incontinent of urine. During the observed care, the CNA washed her hands and donned gloves before starting, but after removing the soiled brief and assisting with positioning the resident, she handled a new brief and completed care without removing her gloves or performing hand hygiene between the contaminated and clean tasks. Interviews with the CNA revealed she did not believe it was necessary to change gloves or wash her hands before applying the new brief, despite having received training on proper hand hygiene. Both the Assistant Director of Nursing (ADON) and Director of Nursing (DON) confirmed that facility policy and training require staff to change gloves and perform hand hygiene before moving from a contaminated to a clean task, such as before applying a new brief. Facility policy and the resident's care plan also supported these expectations, but the CNA did not adhere to them during the observed care.