Failure to Perform Hand Hygiene During Glove Changes in Resident Care
Penalty
Summary
Staff failed to perform proper hand hygiene during incontinence care and treatment for two residents, as observed and confirmed through interviews and record reviews. For one resident with a stage 2 pressure ulcer and a history of incontinence, a medication aide performed perineal care without changing contaminated gloves before reaching into a wipes container and did not perform hand hygiene after removing gloves before applying barrier cream. Facility policies and CDC guidelines require hand hygiene before donning and after removing gloves, as well as glove changes between tasks from contaminated to clean areas, but these were not followed during the observed care. In a separate incident, another resident with impaired skin integrity and a history of incontinence was assisted by a medication aide who changed gloves without performing hand hygiene before applying barrier cream. Interviews with staff, including the RN, unit leader, and DON, confirmed that hand hygiene should be performed when changing gloves, but this was not done during the observed care. Both residents were cognitively intact and dependent on staff for activities of daily living, and their care plans included interventions for proper hand washing technique before and after care.