Failure to Perform Hand Hygiene Between Glove Changes and After Glove Removal
Penalty
Summary
During an observation of care, two CNAs assisted a resident with toileting and perineal care. After providing perineal care, one CNA removed (doffed) used gloves and immediately donned new gloves without performing hand hygiene in between glove changes. Both CNAs then assisted the resident with dressing and transferring to a wheelchair. Subsequently, the CNA removed gloves and, without performing hand hygiene, opened the resident's bedside table drawer and handed the resident a hair comb. The CNA verbally indicated to the resident that she needed to wash her hands, but did not perform hand hygiene herself at the required times. The facility's infection preventionist confirmed during an interview that staff are expected to change gloves when moving from dirty to clean tasks and to perform hand hygiene between glove uses and immediately after removing gloves. Review of the facility's hand hygiene policy also indicated that hand hygiene should be performed after removing gloves and as the final step after removing personal protective equipment. These lapses in infection control practices were directly observed and confirmed through staff interviews and policy review.