Failure to Perform Hand Hygiene Between Glove Changes During Catheter Care
Penalty
Summary
A deficiency was identified when a certified nursing assistant (CNA) failed to perform proper hand hygiene during care for a resident with a supra-pubic catheter. Specifically, after removing gloves following incontinent care and wiping the resident's rectum, the CNA did not sanitize or wash her hands before donning a new pair of gloves to continue with Foley catheter care. This lapse in infection control was directly observed by surveyors during care provided to a male resident with chronic respiratory failure, chronic kidney disease, type 2 diabetes, and moderately impaired cognition, who was dependent on staff for toileting and personal hygiene. The resident's care plan included a goal to remain free of urinary tract infections, and facility policy required hand hygiene after glove removal. The CNA acknowledged forgetting to sanitize her hands between glove changes, and the Director of Nursing and Administrator both confirmed that staff are expected to follow hand hygiene protocols as outlined in facility policy. Review of the CNA's skills checklist indicated she had previously been deemed proficient in hand washing.