Failure to Perform Hand Hygiene and Glove Changes During Resident Care and Dining
Penalty
Summary
Staff failed to maintain proper infection prevention and control practices during both dining and personal care activities. During dining observations, a nursing assistant assisted a resident with eating and then handled another resident's napkin and face without performing hand hygiene. The same staff member then continued to assist the first resident with their drink, again without hand hygiene. Another nurse technician was observed rubbing a resident's shoulder, then feeding two different residents consecutively without performing hand hygiene between residents. During a personal care procedure involving a urinary retention catheter replacement, a nurse technician did not change gloves or perform hand hygiene after cleaning a resident's groin and before assisting with securing a leg strap for the catheter. The staff member continued to hold the resident's hand and perform additional tasks with the same contaminated gloves. The infection preventionist nurse acknowledged the lack of hand hygiene during an interview.