Failure to Change Gloves and Perform Hand Hygiene During Incontinence Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the actions of CNA A during incontinence care for three residents. Observations revealed that CNA A did not change gloves or perform hand hygiene when transitioning from dirty to clean tasks during incontinence care procedures. This practice was observed during care for three male residents, all of whom had a history of bladder and/or bowel incontinence and various medical conditions, including cerebral palsy, schizoaffective disorder, atherosclerotic heart disease, dysphagia, aphasia, and anemia. During the observed care episodes, CNA A and CNA B initially washed their hands and donned clean gloves before starting incontinence care. However, CNA A proceeded to remove soiled briefs, cleanse the residents' groin and buttocks, and then immediately placed clean briefs and assisted with clothing adjustments without changing gloves or performing hand hygiene between dirty and clean tasks. This sequence was repeated for all three residents, despite the facility's infection control policy requiring glove changes and hand hygiene when moving from dirty to clean procedures. Interviews with CNA A, the DON, and the Administrator confirmed that CNA A had received training on proper glove use and hand hygiene but failed to follow protocol during the observed care. Both the DON and Administrator acknowledged the expectation for staff to change gloves and perform hand hygiene as per facility policy. The facility's infection control policy, last revised in October 2018, was reviewed and found to require these practices to prevent the transmission of infections.