Failure to Perform Hand Hygiene Between Glove Changes During Resident Care
Penalty
Summary
The facility failed to maintain proper infection prevention and control practices as observed during direct resident care. On one occasion, two CNAs entered a resident's room to provide peri-care. Both staff members sanitized their hands and donned gloves before beginning care. During the process, one CNA removed her soiled gloves, reached into her shirt pocket for a new pair, paused, and then obtained gloves from a box in the resident's bathroom. She donned the new gloves without performing hand hygiene between glove changes. The care was completed, and both CNAs performed hand hygiene only after removing their gloves and before leaving the room. Staff interview confirmed that hand hygiene should have been performed after removing dirty gloves and before donning new gloves, in accordance with CDC guidelines. The DON also stated that the expectation for direct care staff is to wash their hands between glove changes. The failure to follow these infection control protocols was observed and acknowledged by staff, indicating a lapse in adherence to established hand hygiene practices.