Failure to Follow Hand Hygiene Protocol During Incontinence Care
Penalty
Summary
A nurse aide failed to follow the facility's infection control policy for hand hygiene during incontinence care for a resident. Continuous observation showed that the nurse aide, while wearing gloves, performed multiple tasks including cleaning urine, applying skin barrier ointment, repositioning the resident, and handling various items in the resident's environment without removing gloves or performing hand hygiene between tasks. The aide only removed gloves at the end of care, disposed of them, picked up the trash bag, and exited the room without performing hand hygiene after glove removal. Interviews with the nurse aide revealed that glove changes were only performed if gloves were visibly soiled, and hand hygiene was typically done when exiting the resident's room. The Director of Nursing, Administrator, and Infection Preventionist all stated that their expectation was for staff to remove gloves and perform hand hygiene when moving from dirty to clean tasks, after incontinence care, and before continuing with other care activities. The facility's policy also required hand hygiene after glove removal and after contact with bodily fluids.