Failure to Perform Hand Hygiene During Incontinent Care
Penalty
Summary
Facility staff failed to adhere to established infection prevention and control protocols during incontinent care for three residents. Observations revealed that staff did not perform hand hygiene before starting care, after cleaning soiled areas, or after removing gloves. Staff were also seen touching clean briefs, residents' clothing, bedding, and personal items without changing gloves or performing hand hygiene. In one instance, a staff member used a single wipe multiple times and wiped from back to front, contrary to policy. Additionally, a clean brief was placed on a resident while the dirty brief was still in place, resulting in contact between the clean and soiled briefs. Interviews with staff indicated a lack of understanding regarding the negative outcomes of not performing hand hygiene, with some staff unable to articulate the risks or proper procedures. Record review confirmed that facility policies require hand hygiene before and after resident care, after glove removal, and specify correct perineal care techniques. Despite these policies, staff actions did not align with the documented procedures, leading to the identified deficiency.