Failure to Perform Hand Hygiene and Change Gloves During Incontinence Care
Penalty
Summary
During an observation, a Certified Nursing Assistant (CNA) was seen performing incontinence care for a resident with severe cognitive impairment and total dependence on staff for personal care. The CNA initially performed hand hygiene and donned gloves, but after removing the resident's soiled brief, the CNA, while still wearing the same contaminated gloves, searched through the resident's bedside drawer and dresser to retrieve a tube of cream. The CNA then applied the cream to the resident's perineal area and placed a clean brief on the resident, continuing to wear the same gloves throughout these tasks. The CNA also repositioned the resident and handled clean linens without changing gloves or performing additional hand hygiene. Interviews with the CNA and an LPN confirmed that hand hygiene and glove changes should have occurred when moving from dirty to clean tasks and when touching the resident's environment. Facility policy and protocols reviewed indicated that staff were trained to avoid touching clean items or surfaces with soiled gloves and to perform hand hygiene when moving between contaminated and clean body sites. The failure to follow these procedures was directly observed and acknowledged by staff and facility leadership.