Failure to Follow Hand Hygiene and Glove Protocols During Resident Care
Penalty
Summary
The facility failed to maintain proper infection prevention and control practices for two residents during direct care activities. In one instance, a CNA changed gloves without sanitizing or washing hands while emptying a resident's colostomy bag, and again after cleaning the bag, only sanitizing hands after all tasks were completed. The CNA acknowledged receiving hand hygiene training and recognized the need to sanitize or wash hands between glove changes, especially after contact with body fluids. The Director of Nursing confirmed that the CNA should have sanitized or washed hands between glove changes according to facility policy. In another case, a respiratory therapist changed gloves without performing hand hygiene while providing tracheostomy care for a resident who was totally dependent on staff, had a tracheostomy, and required oxygen therapy. Additionally, an LVN donned gloves and a gown, then touched the privacy curtain and bed controls before administering medication through a PEG tube without changing gloves. The Director of Nursing stated that both the respiratory therapist and LVN failed to follow infection control policy, which could result in the transfer of bacteria and infection to residents. Facility policies reviewed emphasized the importance of hand hygiene and changing gloves when contamination occurs.