Failure to Perform Hand Hygiene and Proper Glove Removal During Resident Care
Penalty
Summary
Certified Nurse Assistants (CNAs) failed to follow proper hand hygiene and glove removal protocols during the care of a resident with severe cognitive impairment, Alzheimer's disease, and frequent incontinence. During an observed episode, the resident had saturated his incontinence brief and pants with urine and had a small amount of stool present. After providing peri care, one CNA did not perform hand hygiene after removing gloves, while another CNA failed to remove her gloves and perform hand hygiene after handling the resident's soiled clothing. This CNA then touched the resident's wheelchair handles, the resident's hands, body, and gait belt, and assisted the resident from bed to wheelchair without changing gloves or performing hand hygiene. Both CNAs also touched the resident's door handle upon leaving the room without performing hand hygiene. Interviews with other CNAs indicated that they were aware of the facility's policy requiring hand washing before donning gloves and after removing them, as well as after handling soiled linen and before touching other surfaces or residents. The facility's policy, dated 2016, specifically states that hands must be washed before and after glove use, and that gloves should be changed often as they become contaminated. The observed actions of the CNAs were inconsistent with both the facility's policy and the stated practices of other staff members.