Failure to Perform Proper Hand Hygiene and Gloving During Resident Care
Penalty
Summary
Staff failed to perform proper hand hygiene and gloving procedures during care for three residents, as observed and documented in the facility. The facility's policies required hand hygiene before and after glove use, after contact with potentially contaminated surfaces, and between clean and soiled tasks. However, multiple instances were observed where staff did not follow these protocols, leading to opportunities for cross contamination. For one resident with quadriplegia and multiple complex medical conditions, a registered nurse and a nurse aide provided catheter and perineal care. During the procedure, the nurse touched various surfaces and assisted the resident with a drink without changing gloves or using hand sanitizer between tasks. The nurse also handled supplies and resident belongings with contaminated gloves, and only performed hand hygiene at the end of the procedure. The nurse confirmed during an interview that these actions could have led to cross contamination. In another case, two nurse aides provided perineal care to a resident with heart failure, diabetes, and other chronic conditions. One aide changed gloves without performing hand hygiene and used a brief that had fallen on the floor, placing it under the resident. The aide acknowledged these actions could have resulted in bacterial contamination. Additionally, during wound care for a resident with Parkinson's disease and suspected MRSA, a nurse donned gloves without hand hygiene, touched the light switch and other surfaces, and moved between clean and soiled areas without sanitizing hands. The nurse confirmed these lapses in infection control during an interview.