Failure to Perform Proper Hand Hygiene During Resident Care
Penalty
Summary
A nursing assistant (NA) failed to follow proper hand hygiene protocols during toileting and incontinence care for a resident with hemiplegia and hemiparesis following a stroke, who was dependent for all transfers and toileting. The NA applied gloves without performing hand hygiene before care, cleaned the resident after a bowel movement using wet wipes, and then proceeded to pull up the resident's pants and handle the wheelchair with the same soiled gloves. The NA did not remove gloves or perform hand hygiene between these tasks, despite being prompted by the surveyor. The NA only washed her hands after completing all care tasks and handling the resident's blanket. Interviews with the NA, a registered nurse (RN), and the director of nursing (DON) confirmed that the expected protocol was not followed, as hand hygiene should have been performed before and after glove use, and gloves should have been changed after peri care. The facility's hand hygiene policy also indicated that hand hygiene is required when moving from a contaminated to a clean body site during resident care. The failure to adhere to these procedures was observed and documented during the survey.