Failure to Follow Hand Hygiene Protocols During Incontinent Care
Penalty
Summary
Certified Nursing Assistants (CNAs) H and I failed to perform proper hand hygiene before providing incontinent care to a resident with multiple diagnoses, including vascular dementia, schizoaffective disorder, hypertension, type 2 diabetes mellitus, and irritable bowel syndrome. The resident was always incontinent of bowel and bladder and had a care plan addressing impaired skin integrity due to a history of excoriation. During observation, both CNAs did not wash their hands after entering the resident's room and before starting care. Additionally, CNA H did not sanitize his hands between changing gloves after cleaning the resident's buttocks and before handling clean briefs. During interviews, both CNAs acknowledged they had not washed their hands before care and that CNA H did not use sanitizer between glove changes, stating they forgot but understood the importance of hand hygiene. The facility's policy required handwashing before and after direct resident contact and the use of alcohol-based hand rub before moving from a contaminated to a clean body site and after removing gloves. The Director of Nursing confirmed the expectation for staff to follow these procedures and stated that infection control training and skills checks were provided at least annually.