Failure to Follow Hand Hygiene Procedures During Peri-Care
Penalty
Summary
Staff failed to follow established hand hygiene procedures during the provision of peri-care for two residents. Facility policy and infection control standards require staff to perform hand hygiene before and after direct contact with residents, after contact with blood or body fluids, and before and after wearing gloves. Observations revealed that nurse assistants changed gloves without using hand sanitizer or washing their hands and did not perform hand hygiene prior to exiting the residents' rooms after providing peri-care. One resident involved was chairfast, required maximum to total assistance for mobility and hygiene, and had multiple chronic conditions including venous stasis ulcers and chronic respiratory failure. During peri-care, two nurse assistants donned appropriate PPE but failed to use hand sanitizer or wash their hands when changing gloves and before leaving the room. Both confirmed in interviews that they did not follow proper hand hygiene protocols. Another resident, admitted for skilled nursing care following a cerebral infarction and with moderate cognitive impairment, also required substantial assistance with personal hygiene and was always incontinent of bowel and frequently incontinent of urine. During peri-care, two nurse assistants used hand sanitizer before entering the room and donned gloves, but did not change gloves or perform hand hygiene during care or before exiting. Both acknowledged in interviews that they should have performed hand hygiene as required by facility policy. The Director of Nursing confirmed the expectation for glove changes and hand hygiene during peri-care and noted the absence of a specific peri-care policy.