Failure to Follow Hand Hygiene and Glove Protocols During Perineal 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 perineal care for two residents with bowel and bladder incontinence. In both cases, certified nursing assistants (CNAs) did not perform hand hygiene before care, did not change gloves when moving from dirty to clean tasks, and touched clean items and room surfaces with soiled gloves. Specifically, one CNA performed perineal care, handled clean briefs, opened drawers, applied barrier cream, and adjusted the resident's environment without changing gloves or performing hand hygiene. The other CNA similarly failed to change gloves or sanitize hands while cleaning the resident, handling clean briefs and clothing, and changing bed linens. Both residents involved were care planned for incontinence and required assistance with perineal cleansing. The CNAs confirmed during interviews that they did not follow proper hand hygiene and glove-changing protocols as outlined in the facility's policy. The Director of Nursing also acknowledged that staff are expected to perform hand hygiene before care, when moving from dirty to clean, and after care, and to avoid touching items in the resident's room with soiled gloves.