Failure to Maintain Proper Hand Hygiene During Incontinent Care
Penalty
Summary
Certified Nursing Assistants (CNAs) failed to adhere to proper hand hygiene protocols while providing incontinent care to a resident with multiple comorbidities, including diabetes mellitus type 2, severe obesity, and moderate cognitive impairment. During the observed care, both CNAs wore gowns and gloves, but after cleaning the resident, one CNA did not perform hand hygiene after changing gloves or when transitioning from dirty to clean supplies. The other CNA, after removing a soiled brief and cleaning the resident, touched clean linens and adjusted a clean brief without changing gloves or performing hand hygiene. Both CNAs only completed hand hygiene after the care was finished and gloves were removed. Interviews revealed that one CNA acknowledged the need for hand hygiene after glove changes and when moving from dirty to clean, as trained by the facility, but apologized for not having hand sanitizer available during care. The other CNA was unclear about the specific requirements for hand hygiene after glove changes or when moving from dirty to clean, stating she was not trained in those aspects. The Director of Nursing confirmed that infection control in-services were conducted regularly and that staff were expected to follow the hand hygiene policy, which requires hand hygiene before and after resident contact, between glove changes, and after soiled hands. Facility policy and recent in-service documentation supported these requirements.