Failure to Follow Hand Hygiene and Infection Control Protocols During Resident Care
Penalty
Summary
Staff failed to maintain proper infection prevention and control practices during the care of a resident with multiple diagnoses, including hypertension, diabetes mellitus, cerebral palsy, and anxiety disorder. The resident required substantial to maximal assistance for transfers and toileting. During an observed transfer to the commode using a sit-to-stand lift, a CNA applied compression socks and braces to the resident's lower legs while wearing gloves, then removed the gloves without performing hand hygiene. The CNA and another staff member continued with the transfer process, including removing the resident's incontinence brief and placing it in the commode with bare hands, again without performing hand hygiene afterward. Further, the CNA handled the resident's clothing and placed soiled garments directly on the floor, donned new gloves without prior hand hygiene, and continued to assist the resident without following proper infection control protocols. Hand hygiene was only performed at the end of the care episode, after multiple opportunities were missed. The facility's policy required hand hygiene before and after direct resident contact, after glove removal, and after contact with soiled items, but these procedures were not followed during the observed care.