Failure to Follow Hand Hygiene and Glove Change Protocols During Personal Care
Penalty
Summary
A nursing assistant (NA) failed to follow proper hand hygiene and glove use protocols while assisting a resident who required help with toileting, dressing, and grooming. During personal care, the NA did not use hand sanitizer or don gloves before assisting the resident to the toilet. After cleaning the resident following a bowel movement, the NA continued to wear the same soiled gloves while helping the resident with clean clothing, flushing the toilet, and handling other items in the resident's room, without performing hand hygiene or changing gloves between tasks. Interviews with facility staff, including an LPN, RN, DON, and the administrator, confirmed that the expectation was for staff to change gloves and perform hand hygiene after contact with feces and before touching clean items to prevent cross-contamination. The facility's hand hygiene policy also directed staff to change gloves and perform hand hygiene when moving from a contaminated to a clean body site. The NA's actions were inconsistent with both facility policy and staff expectations, resulting in a failure to prevent potential cross-contamination during resident care.