Failure to Follow Proper Hand Hygiene During Ostomy Care
Penalty
Summary
During an observation of colostomy care for a resident with multiple diagnoses including dementia, diabetes, dysphagia, depression, hypothyroidism, hypertension, and ileostomy status, a Licensed Vocational Nurse (LVN) failed to follow proper infection control procedures. Specifically, while providing ileostomy care, the LVN used hand sanitizer between glove changes after removing the collection bag and after cleaning the stoma, but did not sanitize between her fingers as required by facility policy. This lapse was confirmed during an interview with the LVN, who acknowledged not sanitizing between her fingers and recognized the importance of this step in preventing cross contamination. The resident involved required total assistance with activities of daily living, was always incontinent of bladder, and had an ostomy. The facility's hand hygiene policy, dated 10/2022, specifies that all surfaces of the hands and fingers must be covered with sanitizer until dry. The Director of Nursing (DON) confirmed that staff are trained at least annually on infection control practices, including proper hand sanitization techniques, and that skills are checked at least annually. Despite this, the observed failure to sanitize between fingers during care represented a breach of the facility's infection prevention and control program.