Failure to Follow Hand Hygiene and Glove Use Standards During Personal and Wound Care
Penalty
Summary
Surveyors identified a failure to follow the facility’s hand hygiene policy and infection prevention standards during personal care for one resident. Observation showed a CNA transferring a resident to the toilet using a stand lift and removing the resident’s wet brief without wearing gloves. The CNA then applied gloves without performing hand hygiene, placed a clean brief on the resident, removed the gloves, and wiped her hands on her pants. Without completing hand hygiene, the CNA applied new gloves, performed perineal care, removed the gloves, assisted the resident back to bed, and exited the room without performing hand hygiene. The facility’s hand hygiene policy required hand hygiene before and after direct resident contact, when assisting with personal care and toileting, and after removing gloves. Surveyors also identified infection control failures during wound care for another resident who required enhanced barrier precautions due to a chronic right thigh ulcer, colostomy, and suspected MRSA carrier status. Observation showed a nurse donning a gown and gloves and entering the resident’s room without performing hand hygiene. The nurse obtained supplies from a dresser, placed them on the bedside table, removed the existing dressing from the right hip wound, and cleaned drainage from the wound. Without removing the soiled gloves, the nurse opened clean dressings, cleansed the wound with normal saline, patted it dry with gauze, and applied and taped a new dressing. The nurse then removed the gown and soiled gloves and exited the room without performing hand hygiene before entering or after exiting the room, and without changing gloves and performing hand hygiene between the soiled and clean portions of the dressing change. An administrative nurse stated she expected staff to perform hand hygiene with alcohol-based hand sanitizer after resident care, between glove changes, and during dressing changes.
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