Failure to Perform Hand Hygiene During Incontinence Care
Penalty
Summary
Certified Nursing Assistant (CNA) A failed to perform proper hand hygiene during the provision of incontinence care to a male resident with moderate vascular dementia, hypertension, and anxiety. The resident was always incontinent and required extensive assistance with activities of daily living, including hygiene. During the observed care, CNA A changed gloves multiple times without performing hand hygiene between glove changes, despite handling soiled briefs and cleaning the resident's perineal and buttocks areas. The CNA acknowledged not sanitizing or washing hands between glove changes and stated awareness of the correct procedure. The Director of Nursing (DON) confirmed that staff are expected to sanitize hands upon entering the resident's room, before and after care, and specifically during glove changes in incontinence care. Facility policy, revised earlier in the year, also required hand hygiene after removing gloves and before client contact. The failure to follow these procedures was directly observed and confirmed through staff interviews and policy review.