Failure to Follow Hand Hygiene Protocol During Incontinence Care
Penalty
Summary
The facility failed to follow proper hand hygiene practices during incontinence care for one of four sampled residents. During an observation, two CNAs provided incontinence care to a resident but did not remove their gloves or perform hand hygiene before applying a clean brief and adjusting the resident's clothing. The facility's Perineal Care Audit Tool specifies that staff should stop, remove gloves, wash or sanitize hands, and don clean gloves before proceeding with clean briefs and clothing. Interviews with the Director of Nursing Services and one of the CNAs confirmed that the expected procedure was not followed during the observed care. The resident involved had a diagnosis of Alzheimer's Disease and was noted to have severely impaired cognitive skills for daily decision making. The CNA involved acknowledged not changing gloves or performing hand hygiene during the care and understood the importance of proper technique. The Administrator confirmed that staff are expected to follow infection control standards as outlined in facility policy and training.