Failure to Perform Hand Hygiene Between Glove Changes During Incontinent Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program as evidenced by a certified nursing assistant (CNA) not performing hand hygiene between glove changes during incontinent care for a resident. During the observed care, the CNA performed hand hygiene and donned gloves before starting, but after removing gloves following perineal cleaning, did not perform hand hygiene before putting on a new pair of gloves. This process was repeated when the CNA changed gloves again to assist the resident with clean clothing, again omitting hand hygiene between glove changes. Interviews with the CNA confirmed awareness of the requirement to perform hand hygiene between glove changes, but the CNA stated that the step was skipped due to working too quickly. The Director of Nursing (DON) also confirmed the expectation for hand hygiene before and after glove use and after providing care. Review of facility policies on hand hygiene and perineal care further supported that hand hygiene is required after glove removal and before donning new gloves, especially after contact with soiled or contaminated articles and after providing personal care.