Failure to Perform Hand Hygiene Between Glove Changes During Incontinent Care
Penalty
Summary
A deficiency was identified when a certified nursing assistant (CNA) failed to perform proper hand hygiene during incontinent care for a female resident with dementia and severe cognitive impairment. During the observed care, the CNA removed her gloves but did not wash or sanitize her hands before donning new gloves, contrary to the facility's hand hygiene policy. The CNA acknowledged during an interview that she forgot to perform hand hygiene between glove changes, despite recent in-service training on infection control and hand washing. Interviews with the Director of Nursing (DON) and Assistant Director of Nursing (ADON) confirmed that the CNA should have washed or sanitized her hands between glove changes to prevent cross-contamination. The facility's policy, reviewed as part of the investigation, clearly states that hand hygiene must be performed prior to donning gloves and immediately after removing them. This lapse in infection control practices was observed and verified through staff interviews and record review.