Failure to Follow Hand Hygiene and Glove Protocols During Incontinence 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 incontinence care for one resident. The resident, an elderly male with dementia, muscle weakness, and severe cognitive impairment, required extensive assistance with personal hygiene and was frequently incontinent. During observed care, a CNA entered the resident's room, donned gloves, and performed incontinence care without changing gloves or performing hand hygiene between dirty and clean tasks. The CNA handled clean briefs and gloves with potentially contaminated hands and did not change gloves or wash hands before moving from soiled to clean procedures. Additionally, the CNA carried gloves into the room before performing hand hygiene, contrary to facility policy. An LVN was also observed entering the room holding gloves in her hands, washing hands, and then donning the gloves, but she had previously handled the gloves before hand hygiene. Both the CNA and LVN acknowledged during interviews that they did not follow proper hand hygiene and glove protocols, and the DON confirmed that staff are required to perform hand hygiene before and after care, and to change gloves between dirty and clean tasks. Facility policy states that hand hygiene is the primary means to prevent infection and must be performed after removing PPE and before donning clean gloves. These lapses in infection control practices were directly observed and confirmed through staff interviews and record review.