Failure to Follow Hand Hygiene Protocols During Resident Care and Medication Administration
Penalty
Summary
Staff failed to follow accepted standards of practice for hand hygiene during personal care and medication administration for five residents. In multiple observed instances, a licensed nurse prepared insulin injections while wearing gloves, then pushed residents in their wheelchairs to their rooms without changing gloves or performing hand hygiene before administering the injections. This occurred with residents who had diagnoses such as Type 2 Diabetes Mellitus. Certified Nursing Assistants (CNAs) were observed entering resident rooms without performing hand hygiene, assisting residents with toileting and perineal care while wearing the same gloves throughout multiple tasks, and failing to perform hand hygiene between glove changes or after removing gloves. In some cases, CNAs assisted residents with pulling up pants and moving them to common areas without offering hand hygiene to the residents or performing it themselves. These actions were observed with residents who had conditions including dementia, chronic kidney disease, heart failure, and fractures. Interviews with staff confirmed knowledge of hand hygiene protocols, but lapses were attributed to forgetfulness. The facility's own hand hygiene policy required hand hygiene before patient encounters, after contact with patient skin, between tasks on the same patient, after glove removal, and after handling patient equipment or toileting. These requirements were not consistently followed during the observed care activities.