Failure to Perform Proper Hand Hygiene During Incontinence Care
Penalty
Summary
The facility failed to maintain an effective Infection Prevention and Control Program, as evidenced by multiple instances of staff not performing proper hand hygiene during incontinence care for two residents. For the first resident, a male with diagnoses including diabetes, hemiplegia, and viral hepatitis, two CNAs entered the room to provide care. Both CNAs donned gloves and gowns, but neither performed hand hygiene before putting on gloves. During the care process, gloves were changed without hand hygiene, and one CNA left the room with trash without sanitizing her hands. The resident expressed concern that not all soiling was removed from his groin area, and both CNAs later acknowledged missing required hand hygiene steps during the procedure. For the second resident, a female with seizures, hemiplegia, and mild cognitive impairment, two CNAs sanitized their hands before entering the room and donned gloves and gowns. However, during perineal care, one CNA used the same gloves to clean the resident and then to place a clean brief and reposition her, without changing gloves or performing hand hygiene between these steps. Both CNAs only removed their gloves and washed their hands after completing all care and repositioning tasks, contrary to facility policy. Interviews with the involved CNAs confirmed their awareness of the required hand hygiene protocols, including performing hand hygiene before care, after glove changes, and before leaving the resident's room. Facility policies reviewed emphasized the importance of hand hygiene as the primary means to prevent infection, specifying that glove use does not replace hand hygiene and that hand hygiene must be performed at key points during resident care. Despite this, the observed failures in hand hygiene and glove changes during incontinence care led to the cited deficiency.