Failure to Perform Hand Hygiene After Incontinence Care
Penalty
Summary
During the provision of incontinence care for one resident, a Certified Nursing Assistant (CNA) failed to follow the facility's hand hygiene policy. After providing peri-care and removing soiled gloves, the CNA did not perform hand hygiene or don clean gloves before touching the resident's legs, back, and a tube of barrier cream. This lapse was observed by a surveyor, who noted that the CNA only performed hand hygiene after being questioned about it. The facility's policy, revised in November 2022, requires staff to perform hand hygiene after removing gloves and after handling items potentially contaminated with bodily fluids. The CNA confirmed during an interview that hand hygiene was not completed as required, and the Director of Nursing also acknowledged that the correct procedure was not followed in this instance.