Failure to Follow Hand Hygiene and Glove Use During Incontinence Care
Penalty
Summary
Staff failed to follow appropriate infection control practices during incontinence care for two residents who were dependent on staff for all activities of daily living and were always incontinent of bowel and bladder. In one instance, a CNA provided peri care to a resident, then, without changing gloves or performing hand hygiene, touched a barrier cream container, applied the cream, continued care to the resident's buttocks, and applied a new brief, all with the same soiled gloves. The CNA only removed gloves and washed hands after completing the care and handling soiled materials. The CNA confirmed in an interview that she did not change gloves or wash hands between steps as required. In another instance, a different CNA performed incontinence care for a resident, including removing a soiled brief, washing the resident's peri area and buttocks, and applying a clean brief, all without changing gloves or performing hand hygiene. The CNA then pulled up the covers and lowered the bed while still wearing the soiled gloves. The CNA confirmed in an interview that she did not change gloves or wash hands before applying the clean brief and handling the resident's environment. The facility's policy and CDC guidelines require glove changes and hand hygiene after contact with body fluids and before moving from a soiled to a clean site, which was not followed in these cases.