Failure to Perform Hand Hygiene Between Glove Changes During Peri Care
Penalty
Summary
A certified nursing assistant (CNA) failed to follow proper infection control procedures while providing peri care to a male resident with severe cognitive impairment, hemiplegia, and incontinence. During the care, the CNA changed gloves multiple times without sanitizing or washing hands between glove changes, despite the facility's policy requiring hand hygiene between glove changes. This was observed while the CNA cleaned the resident's groin, buttock, and rectal areas and replaced the resident's brief. Interviews with the CNA and the Director of Nursing (DON) confirmed that hand hygiene should have been performed before donning new gloves to prevent infection. The facility's hand hygiene policy, revised in January 2023, specifically required the use of alcohol-based hand rub or soap and water between glove changes. The failure to adhere to this policy was directly observed and acknowledged by both the CNA and the DON.