Failure to Perform Hand Hygiene During Incontinence Care
Penalty
Summary
Staff failed to follow infection control standards during incontinence care for two residents. Specifically, certified nurse aides did not wash their hands after removing dirty gloves and before donning clean gloves to apply a clean brief. This was observed during care for two residents, where the aides discarded dirty briefs and gloves but did not perform hand hygiene as required by facility policy. The facility's infection prevention policy, dated 10/15/24, requires hand washing or hand rub when moving from a contaminated to a clean body site and immediately after removing personal protective equipment. Interviews with staff confirmed that they had received training on proper hand hygiene but missed this step during the observed care. The Infection Preventionist and Director of Nursing both stated that the expectation is for staff to wash their hands between clean and dirty care processes.