Failure to Perform Hand Hygiene During Incontinent Care
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, as evidenced by improper hand hygiene practices during incontinent care for one resident. During an observation, a CNA performed perineal care and changed gloves multiple times without performing hand hygiene between glove changes, despite being trained to do so. The CNA acknowledged during an interview that she did not complete hand hygiene after glove changes and recognized this as a lapse in protocol. The resident involved was an elderly female with diagnoses including major depressive disorder, hypertension, and a hip fracture, who was admitted recently and had a care plan that did not address infection control interventions. Interviews with other staff, including an LVN and the DON, confirmed that facility policy and training require hand hygiene before, during, and after incontinent care, especially when changing gloves. Review of facility in-service training records and policy documents further supported that hand hygiene is expected at specific points during care. The observed failure to follow these protocols was directly contrary to both facility policy and staff training, as documented in the records and staff interviews.