Failure to Perform Hand Hygiene Between Glove Changes During Incontinent Care
Penalty
Summary
A certified nursing assistant (CNA) failed to follow proper hand hygiene protocols during incontinent care for a resident with severe cognitive impairment, Parkinson's Disease, acute respiratory failure, and incontinence of bowel and bladder. During the observed care, the CNA washed her hands and donned personal protective equipment (PPE) before beginning care, but after removing her gloves, she did not sanitize her hands before putting on a new pair of gloves and continuing with the procedure. The CNA completed the care and washed her hands only after removing her PPE at the end of the process. The CNA later acknowledged in an interview that she skipped the hand sanitizing step between glove changes, attributing it to being in a hurry, despite having received training on hand hygiene during orientation. Interviews with the administrator (ADM) and director of nursing (DON) revealed that they were not aware staff were omitting hand hygiene between glove changes during resident care. Both acknowledged that proper hand hygiene is necessary to prevent the spread of bacteria and infection, and that staff are trained and monitored for compliance. Review of the facility's hand hygiene policy confirmed that hand hygiene is required immediately after glove removal and before moving from a soiled to a clean body site on the same resident. The failure to follow these protocols was observed and confirmed through staff interviews and record review.