Failure to Perform Hand Hygiene Between Glove Changes During Resident Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by improper hand hygiene practices during incontinent care for a resident. During an observation, a CNA provided perineal care to a resident with multiple medical conditions, including hemiplegia, prostate cancer, stroke, and dysphagia, who was dependent on staff for personal hygiene and was always incontinent. The CNA was observed removing and changing gloves multiple times throughout the care process without washing or sanitizing her hands between glove changes, despite having hand sanitizer available. Interviews with the CNA confirmed that she did not perform hand hygiene between glove changes during the care episode, acknowledging the risk of infection associated with this lapse. The CNA had previously received training and was deemed proficient in perineal care and hand hygiene, as documented in her records. Facility leadership, including the ADON and DON, stated that staff are trained annually on infection control practices, including the requirement for hand hygiene before, during, and after care, and specifically between glove changes. A review of the facility's hand hygiene policy indicated that hand hygiene is required after glove removal and that the use of gloves does not replace hand washing or hand hygiene. The policy also specifies the use of alcohol-based hand rubs for most clinical situations and outlines the indications for hand hygiene, including after contact with contaminated surfaces and between work on soiled and clean body sites. Despite these policies and training, the observed failure to perform hand hygiene between glove changes during resident care constituted a breach in infection control protocols.