Failure to Perform Hand Hygiene After Glove Removal
Penalty
Summary
A deficiency was identified when a licensed vocational nurse (LVN) failed to perform hand hygiene after removing gloves and before donning a new pair of gloves while providing care to a resident. The LVN was observed administering medications to a resident, removing her gloves, and then immediately putting on a new pair of gloves without washing her hands or using an alcohol-based hand sanitizer. This action occurred at the resident's bedside and was directly observed by surveyors. The resident involved had multiple medical conditions, including orthostatic hypotension, a gastrostomy tube, diastolic heart failure, and Parkinsonism, and was totally dependent on staff for activities of daily living. The facility's policy required staff to perform hand hygiene after removing personal protective equipment (PPE) and before resident contact, but this protocol was not followed. Both the LVN and the Director of Nursing acknowledged during interviews that hand hygiene should have been performed to prevent the spread of infection.