Failure to Perform Proper Hand Hygiene During Incontinent Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program as evidenced by improper hand hygiene practices among staff during incontinent care for two residents. In one instance, a CNA performed multiple glove changes while providing care, including opening a wet brief, wiping the resident's vaginal area and bottom, applying lotion, and putting on a clean brief, but did not perform hand hygiene between glove changes. Although the CNA had previously been checked off on proper handwashing techniques, she stated that hand hygiene was not necessary between glove changes. In another instance, a CNA disposed of a dirty wipe after receiving it from another CNA during incontinent care, but did not change gloves or perform hand hygiene before handing over clean wipes and a clean brief. The CNA acknowledged the lapse, attributing it to nervousness. Interviews with the DON and Administrator revealed differing expectations regarding hand hygiene, with the DON expecting hand hygiene before care, between dirty and clean tasks, after care, and between glove changes, while the Administrator emphasized hand hygiene before and after glove use and when hands are visibly soiled. The facility's policy indicated that hand hygiene is the primary means to prevent the spread of healthcare-associated infections and outlined specific indications for hand hygiene.