Failure to Follow Hand Hygiene and Glove Protocols During Resident Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by improper hand hygiene and glove use during resident care. During urostomy care for a 90-year-old male resident with a history of urinary tract infection, neuromuscular bladder dysfunction, muscle weakness, and Alzheimer's disease, an LVN did not change gloves or perform hand hygiene after her gloves became visibly soiled. She continued to handle clean supplies and complete the procedure with the same soiled gloves, only washing her hands after the care was finished. The LVN acknowledged during interview that she should have performed hand hygiene and changed gloves before handling clean items, attributing her lapse to nervousness. In a separate incident, a CNA providing incontinence care to an 81-year-old female resident with neuromuscular bladder dysfunction, urinary retention, and dementia, failed to wash his hands before donning gloves and did not change gloves or perform hand hygiene after cleaning fecal matter. The CNA continued care with visibly soiled gloves, placed a clean brief on the resident, and exited the room without washing his hands. During interview, the CNA admitted to not following proper infection control practices and noted a lack of recent infection control training, especially for night shift staff. The facility's Director of Nursing confirmed awareness of infection control concerns and stated that infection control training is provided at hire and annually, with periodic spot checks and return demonstrations. The facility's hand hygiene policy requires staff to perform hand hygiene at specific times, including when hands are visibly soiled and after contact with residents with infectious diarrhea. Despite these policies, staff failed to adhere to required infection control practices during resident care.