Failure to Implement Hand Hygiene and Glove Use Protocols by Housekeeping Staff
Penalty
Summary
The facility failed to implement proper infection prevention and control practices as required by its own policies. Specifically, two housekeeping staff members did not perform hand hygiene after removing gloves and before donning new gloves, as observed multiple times during their cleaning routines. One housekeeper was seen exiting a resident's room wearing gloves, touching the housekeeping cart and various cleaning supplies, and then entering another resident's room without changing gloves or performing hand hygiene. This sequence was repeated, with the staff member continuing to use the same potentially contaminated gloves across different rooms and tasks. Another housekeeper also failed to perform hand hygiene between glove changes and was observed wearing gloves in the hallway, which is against facility policy. Interviews with the housekeeping staff, the unit manager, and the infection control preventionist nurse confirmed that staff are expected to perform hand hygiene before and after glove use, not wear gloves in the hallway, and change gloves between rooms and tasks. Despite this, the observed actions of the housekeeping staff did not align with these expectations, resulting in a failure to follow established infection control procedures designed to prevent the spread of infection among residents, staff, and visitors.