Failure to Perform Proper Hand Hygiene Between Glove Changes During Resident Care
Penalty
Summary
The facility failed to ensure effective hand hygiene practices were followed during resident care, as observed in multiple instances involving two residents. For one resident with multiple sclerosis, vascular disease, and lower extremity ulcers, staff were observed changing gloves without performing hand hygiene between glove changes during perineal care and wound care procedures. Specifically, after removing soiled gloves, staff donned new gloves without washing or sanitizing their hands, despite the presence of bowel movements and wound dressings. Additionally, hand washing performed by staff was observed to be inadequate in duration, with one instance lasting only approximately 7 seconds and another for about 5 seconds, both below the facility's policy requirement. Another resident with a chronic foot ulcer also received wound care in which the nurse removed soiled gloves and immediately donned new gloves without performing hand hygiene in between. Interviews with staff confirmed their awareness that hand hygiene should be performed with each glove change and that hand washing should last at least 20 seconds, as outlined in the facility's hand hygiene policy. However, these procedures were not consistently followed during direct care activities, as documented by surveyor observations.