Failure to Perform Hand Hygiene Between Glove Changes During Resident Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by improper hand hygiene practices during wound and incontinent care for a resident. Specifically, the wound care nurse/acting DON did not perform hand hygiene between glove changes while providing care to a female resident with right side hemiplegia, aphasia, chronic wounds, and a history of incontinence. The resident was on enhanced barrier precautions due to wounds, and signage and PPE were in place as per care plan requirements. During the observed care, the nurse donned gloves and a gown but did not wash or sanitize her hands between glove changes after performing incontinent care and before wound care. She also failed to perform hand hygiene after removing soiled dressings and before applying clean gloves and dressings. Both the nurse and the RNC acknowledged that hand hygiene should have been performed between glove changes, as outlined in the facility's hand hygiene policy, which requires hand hygiene before donning and after removing gloves.