Failure to Perform Proper Hand Hygiene During Perineal Care
Penalty
Summary
Certified Nursing Assistant 3 (CNA 3) failed to follow proper infection control practices while providing perineal care to a resident who was dependent on staff for toileting hygiene, had a history of malignant neoplasm of the breast with secondary brain involvement, and was at risk for pressure ulcers. During the observed care, CNA 3 used the same towel to clean both the front perineal area and the anal/buttocks area, refolding it to use different sections, and did not change gloves or perform hand hygiene (HH) after cleaning the resident's bowel movement. CNA 3 then assisted a treatment nurse with wound dressing changes and subsequently changed the resident's brief and clothing, only performing HH after discarding the soiled items. When questioned, CNA 3 acknowledged that she was supposed to wash her hands and change gloves after cleaning the perineal area and before touching the resident's body, new brief, or clothing, but admitted to performing HH only twice during the entire process. The Infection Preventionist confirmed that CNA 3 did not perform HH at the appropriate times as required by facility policy, specifically after contact with body fluids and before moving from a soiled to a clean body site on the same resident. Facility policies reviewed indicated that hand hygiene is the primary means to prevent the spread of healthcare-associated infections and outlined specific requirements for HH during resident care.