Failure to Follow Hand Hygiene Protocols During Incontinence Care
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, as evidenced by improper hand hygiene practices during incontinence care for one resident. During an observation, a CNA assisted a male resident with severe cognitive impairment and multiple diagnoses, including dementia, neurogenic bladder, and muscle weakness, in changing his wet clothing and providing perineal care. The CNA put on gloves without performing hand hygiene, changed gloves multiple times without sanitizing hands, and continued to assist the resident and his roommate without following proper hand hygiene protocols. The facility's policies required hand hygiene before donning gloves, after glove removal, and when moving from dirty to clean tasks, but these procedures were not followed during the observed care. The resident involved required substantial assistance with personal hygiene due to his cognitive and physical limitations, as documented in his care plan and MDS assessment. Despite these needs and the facility's established policies, the CNA did not perform hand hygiene at any point during the care process, including after removing soiled gloves and before assisting another resident. This lapse in infection control practices was confirmed through interviews with the CNA and the DON, both of whom acknowledged the importance of hand hygiene and the failure to adhere to protocol during the incident.