Failure to Follow Hand Hygiene and Equipment Cleaning Protocols During Resident Transfer
Penalty
Summary
Certified Nursing Assistants (CNAs) failed to adhere to the facility's infection prevention and control policies during the transfer of a resident with multiple medical conditions, including dementia, heart disease, and a recent femur fracture. During an observed transfer using a mechanical lift, two CNAs placed gloves on without performing hand hygiene beforehand, did not perform hand hygiene after removing gloves, and failed to perform hand hygiene at other required points during resident care. Additionally, after the transfer, the mechanical lift was not wiped down as required by facility policy. Both CNAs exited the resident's room without performing hand hygiene, and one CNA handled resident care items and assisted the resident without hand hygiene or glove use. The resident involved was moderately cognitively impaired, dependent on staff for transfers and personal care, and at risk for pressure injuries. The facility's policies clearly require hand hygiene before and after resident contact, after glove removal, and after use of equipment such as mechanical lifts. Despite recent staff training on hand hygiene, the observed staff actions did not comply with these protocols, and no explanation was provided by the facility for the failure to follow infection control procedures.