Failure to Follow Hand Hygiene Protocols During Incontinence Care
Penalty
Summary
The facility failed to maintain proper infection prevention and control practices during incontinence care for one resident. During observation, a CNA provided incontinence care to a female resident with a history of hypertension and chronic obstructive pulmonary disease, who was frequently incontinent of bowel and bladder. The CNA washed his hands before starting care and used gloves while cleaning the resident. However, after removing his soiled gloves, the CNA did not perform hand hygiene before retrieving a clean brief from a cabinet and putting on new gloves. The CNA then continued care, touching clean items and the resident's environment with gloves that had not been changed after cleaning the resident, and only washed his hands after completing the care and before exiting the room. Interviews with the CNA, LVN, DON, and ADON confirmed that the CNA did not follow proper hand hygiene protocols, specifically failing to wash hands or use hand sanitizer between glove changes and after removing soiled gloves. The facility's infection control policy requires hand hygiene before and after assisting a resident with personal care and emphasizes that glove use does not replace the need for hand washing. The failure to adhere to these protocols was directly observed and acknowledged by staff, constituting a deficiency in the facility's infection prevention and control program.