Failure to Follow Hand Hygiene and Glove Change Protocol During Incontinent Care
Penalty
Summary
The facility failed to maintain proper infection prevention and control practices during incontinent care for one resident diagnosed with diarrhea and requiring assistance for toileting due to an ADL self-care performance deficit. During the observed care, two CNAs initially performed hand hygiene and donned gloves. However, when one CNA needed new gloves, the other CNA removed her gloves, retrieved new gloves from a box without sanitizing her hands, and then continued care. After cleaning the resident's bottom, the CNA did not change her gloves or perform hand hygiene before handling a clean brief and placing it under the resident. Both CNAs acknowledged during interviews that gloves should have been changed and hand hygiene performed after contact with soiled areas and before touching clean items. The ADON and Administrator confirmed that the staff did not follow facility policy, which requires hand hygiene before donning gloves and after removing them, as well as changing gloves when moving from dirty to clean tasks. The failure to follow these procedures was directly observed and confirmed through staff interviews and record review.