Failure to Follow Hand Hygiene and Glove Change Protocol During Incontinence Care
Penalty
Summary
A deficiency was identified when a certified nursing assistant (CNA) failed to follow proper infection prevention and control procedures during incontinent/peri care for a resident. The CNA washed her hands initially, but after using the bed remote, she donned gloves without performing hand hygiene. During the care, the CNA used the same pair of gloves to clean both the resident's vaginal area and then the rectal/buttock area, without changing gloves or performing hand hygiene between these tasks. The CNA acknowledged during an interview that she should have changed gloves and performed hand hygiene between these steps, recognizing this as a break in infection control and cross-contamination. The resident involved was a female with multiple diagnoses, including encephalopathy, memory deficit, Parkinson's disease, muscle wasting, lack of coordination, and urinary retention. She was moderately cognitively impaired, required substantial assistance with mobility, and was frequently incontinent of bladder and always incontinent of bowel. Facility policy and the CNA's competency checklist both required proper hand hygiene and glove changes during incontinence care, but these procedures were not followed during the observed incident.