Failure to Perform Hand Hygiene Prior to Glove Use During Diabetes Care
Penalty
Summary
A deficiency was identified when the Unit Coordinator failed to follow the facility's Handwashing/Hand Hygiene policy during the provision of care to two residents. Specifically, the Unit Coordinator did not perform hand hygiene prior to donning clean gloves before conducting blood glucose fingerstick and insulin injections. During one observation, the Unit Coordinator entered a resident's room, removed personal protective equipment to retrieve supplies, and upon returning, donned a new gown and gloves without performing hand hygiene. The insulin injection was then administered without the required hand hygiene step. In another instance, the Unit Coordinator applied antiseptic gel before the initial procedure, but after removing gloves and retrieving additional supplies, again donned clean gloves without performing hand hygiene before continuing with blood glucose testing and insulin administration. Staff interviews confirmed that the Unit Coordinator was aware of the hand hygiene requirements but failed to comply, citing nervousness as the reason for the lapse. The Infection Preventionist and Director of Nursing both acknowledged that hand hygiene should have been performed after glove removal and before subsequent procedures, in accordance with facility policy. The residents involved were receiving routine diabetes care, including blood glucose monitoring and insulin injections, at the time of the observed deficiencies.