Failure to Perform Hand Hygiene During Resident Care
Penalty
Summary
The facility failed to maintain proper infection prevention and control practices for two residents during personal and wound care procedures. For one resident with a neurogenic bladder and an indwelling Foley catheter, a CNA did not perform hand hygiene on two occasions when changing from dirty to clean gloves during perineal and catheter care, despite the presence of Enhanced Barrier Precautions and available PPE. The CNA acknowledged that hand sanitization was required with each glove change but admitted to missing steps due to nervousness. The resident was cognitively intact and required regular catheter care as per care plan and physician orders. In a separate incident, an LVN providing wound care to another resident with a skin tear on the leg failed to sanitize hands between glove changes after removing a soiled dressing and before cleansing the wound. The LVN also attributed the lapse to nervousness, though she was aware of the hand hygiene expectations. Both the DON and Infection Control Practitioner confirmed that facility policy required hand hygiene before donning gloves, between glove changes, and after completing procedures, and that staff were trained on these protocols during orientation and ongoing education. Observations and interviews confirmed that these lapses in hand hygiene occurred during direct care.