Failure to Perform Hand Hygiene During Perineal Care
Penalty
Summary
A Certified Nurse Aide (CNA) failed to perform proper hand hygiene during perineal care for a resident with severe cognitive impairment and a diagnosis of unspecified dementia. The CNA was observed removing gloves and exiting the resident's room without performing hand hygiene, then returning and continuing care without washing hands. Additionally, after completing care, the CNA removed gloves and applied a new pair before putting on a clean brief, again without performing hand hygiene between glove changes. These actions were in direct violation of the facility's Hand Hygiene Policy, which requires hand hygiene before donning gloves, after removing gloves, and when entering or exiting a resident's room. Interviews with facility staff, including a lead CNA, the CNA involved, the Director of Nursing (DON), and the facility's Infection Preventionist, confirmed that the expected protocol was not followed. All staff acknowledged that hand hygiene should have been performed at each indicated step, and the Infection Preventionist confirmed that lapses in hand hygiene could lead to infection in the resident. The deficiency was identified through observation, interviews, and review of facility policy and resident records.