Failure to Perform Hand Hygiene and Use PPE During Resident Care
Penalty
Summary
Staff failed to perform proper hand hygiene before donning gloves and between glove changes during peri-care and catheter care for two residents. In one instance, a medication aide (MA-E) did not wash hands before putting on gloves, nor between glove changes, while providing peri-care to a resident with severe cognitive impairment, Alzheimer's disease, and a history of urinary tract infection. The aide also used Nystatin powder found in the resident's bathroom, which was not brought in from the medication cart, and did not dry the resident's groin area after cleaning. After removing gloves, the aide continued to assist the resident with personal grooming without performing hand hygiene. In another case, two nursing assistants (NA-A and NA-B) provided peri-care and catheter care to a resident with an indwelling Foley catheter and moderate cognitive impairment. Both assistants put on gloves without performing hand hygiene and did not wear gowns as required under Enhanced Barrier Precautions for residents with indwelling devices. During the care, they changed gloves without hand hygiene and did not dry the cleansed areas. After completing care, they performed hand hygiene, but not at the required intervals. Additionally, a registered nurse (RN-C) entered the resident's room already wearing gloves, disposed of a medication cup, applied topical medication, and left the room without performing hand hygiene after glove removal. Interviews with the Director of Nursing confirmed that staff did not follow facility policy, which requires hand hygiene before donning gloves, between glove changes, and after glove removal, as well as the use of gowns for residents under Enhanced Barrier Precautions. The observed failures were consistent with the facility's own infection control policies and procedures, as documented in the report.