Failure to Perform Hand Hygiene and Use PPE During Resident Care
Penalty
Summary
Staff failed to perform proper hand hygiene and use appropriate personal protective equipment (PPE) during direct care of two residents. In the case of one resident with a suprapubic catheter and a history of urinary retention and incontinence, staff did not wash their hands before donning gloves, did not wear gowns as required by enhanced barrier precautions, and failed to change gloves or perform hand hygiene between glove changes during perineal and catheter care. Both the nurse aide and medication aide involved acknowledged these lapses during interviews, and the Director of Nursing confirmed that the expected procedures were not followed. For another resident with hemiplegia, aphagia, and a gastrostomy tube, an LPN donned gown and gloves without performing hand hygiene before administering medications and providing gastrostomy care. The LPN also failed to change gloves or perform hand hygiene when transitioning from medication administration to gastrostomy care, and did not wash hands before leaving the resident's room. The LPN later confirmed these omissions during an interview, and the Director of Nursing reiterated that hand hygiene should have been performed at each step as outlined in facility policy. Facility policies reviewed by surveyors clearly required hand hygiene before donning gloves, after glove removal, and between care tasks, as well as the use of gowns and gloves for high-contact care activities under enhanced barrier precautions. These policies were not followed during the observed care of both residents, as confirmed by staff interviews and direct observation.