Failure to Perform Hand Hygiene During Incontinence Care
Penalty
Summary
Staff failed to follow appropriate hand hygiene protocols during incontinence care for a resident with severe cognitive deficits, total dependence for activities of daily living, and multiple complex medical conditions including post-polio syndrome, intracerebral hemorrhage, type 2 diabetes, and chronic kidney disease. On two separate occasions, certified nurse aides (CNAs) provided care to the resident after an episode of incontinence, including transferring her using a mechanical lift and changing soiled clothing and linens. During these cares, staff removed soiled gloves and either failed to wash their hands or did not use hand sanitizer between glove changes. In both instances, staff left the resident's room without performing required hand hygiene. Facility policies required staff to wear gloves when in contact with blood, body fluids, or excretions, and to discard gloves after a single use. The hand hygiene policy mandated that all personnel follow handwashing procedures to prevent the spread of infection. Despite these policies, direct observation and interviews confirmed that staff did not consistently adhere to hand hygiene protocols during resident care, resulting in a failure to implement the facility's infection prevention and control program.