Failure to Perform Hand Hygiene During Resident Care
Penalty
Summary
The facility failed to ensure proper hand hygiene practices were followed by staff during resident care for three out of four residents reviewed for infection control. In multiple observed instances, staff members, including CNAs and an LPN, did not perform hand hygiene before donning gloves, between glove changes, or after completing resident care and leaving the room. These lapses occurred during the provision of incontinent care and gastrostomy tube (G-tube) care. One resident with severe cognitive impairment and total dependence for activities of daily living was observed receiving incontinent care from two CNAs who donned gloves without prior hand hygiene, changed gloves multiple times without hand hygiene between changes, and left the room without performing hand hygiene. Another resident, also dependent on staff for ADLs and with a history of bowel and bladder incontinence, received peri-care from CNAs who failed to perform hand hygiene before care, between glove changes, and after care. Additionally, an LPN providing G-tube care to a resident did not perform hand hygiene before donning PPE, between tasks, or after doffing PPE and leaving the room. Interviews with facility staff, including the Director of Nursing and CNAs, confirmed the expectation that hand hygiene should be performed before and after resident care, as well as between glove changes. Facility policies also require hand hygiene at these critical points. However, direct observations and record reviews demonstrated that these protocols were not consistently followed during the care of residents with complex medical needs and high dependency.