Failure to Perform Hand Hygiene After Incontinence Care
Penalty
Summary
Staff failed to maintain proper infection control practices after providing care to a resident who was dependent for toileting hygiene and incontinent of bowel and bladder. Two CNAs provided incontinence care, changed the resident's brief, pants, and linen, and then removed their gloves. Both CNAs left the room with soiled items without performing hand hygiene, either by washing their hands or using hand sanitizer. One CNA proceeded to obtain clean linen from a cart used for all residents and returned to the resident's room to place the linen on the bed, still without performing hand hygiene. The other CNA eventually used hand sanitizer, but only after returning to the room following disposal of soiled items. Both CNAs confirmed in interviews that they did not perform hand hygiene after providing peri-care and before moving on to other tasks or residents. Interviews with the DON and Regional Director of Clinical Services confirmed that staff were expected to perform hand hygiene before entering a resident's room, after providing care, and before leaving the room. Review of the facility's hand hygiene policy indicated that hand hygiene is required after direct contact with residents, after contact with bodily fluids, after removing gloves, and before handling clean linen. The policy also stated that glove use does not replace hand hygiene. The failure to follow these procedures was observed and confirmed through staff interviews and policy review, affecting the infection control program for all residents in the facility.