Failure to Perform Hand Hygiene After Personal Care
Penalty
Summary
Staff failed to perform appropriate hand hygiene during and after providing personal care to two residents requiring substantial or maximal assistance with activities of daily living (ADLs). One resident with severe cognitive impairment, dementia, and a traumatic brain injury required assistance with personal hygiene and toileting, including the use of a mechanical lift and catheter care. During observed care, staff donned gowns, gloves, and masks but did not use hand sanitizer before gloving. After performing perineal care and handling bodily fluids, staff continued to wear the same gloves, did not perform hand hygiene after glove removal, and exited the resident's room without washing hands or using hand sanitizer. In a separate instance, staff entered another resident's room—who had left-sided hemiplegia and required assistance with toileting—without performing hand hygiene. The staff member applied gloves, assisted with perineal care, and then removed gloves without washing hands or using hand sanitizer before leaving the room. Interviews with staff confirmed awareness of the hand hygiene requirements, and facility policy mandated hand hygiene at specific moments, including after glove removal and before entering another resident's room. These actions and inactions directly led to the identified deficiency in infection prevention and control.