Failure to Perform Hand Hygiene Between Glove Changes During Peri-Care
Penalty
Summary
A deficiency occurred when a certified nursing assistant (CNA) failed to perform proper hand hygiene during peri-care for a female resident who was totally dependent on staff for toileting and incontinent. The resident, who had diagnoses including type 2 diabetes mellitus with diabetic neuropathy, congestive heart failure, and generalized muscle weakness, required total assistance for toilet hygiene. During an observed episode of peri-care, the CNA removed soiled gloves after handling a large volume of stool and immediately donned clean gloves without performing hand hygiene in between, despite her gloves being visibly contaminated. Interviews with the CNA, the Assistant Director of Nursing (ADON) who also served as the facility's Infection Preventionist, and the Director of Nursing (DON) confirmed that the facility's expectation and policy required staff to perform hand hygiene after removing gloves and before putting on new gloves, especially during peri-care. The CNA acknowledged awareness of the correct procedure but failed to follow it during the observed care. Facility records indicated the CNA had previously been assessed as proficient in both peri-care and infection control awareness. Facility policies reviewed also specified the necessity of hand hygiene before and after glove use, particularly when gloves are visibly soiled.