Failure to Ensure Proper Hand Hygiene During Incontinence Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program for one resident reviewed for infection control. During incontinence care, a CNA performed hand hygiene and donned gloves before beginning care, but after removing soiled gloves and touching the resident's curtain with bare hands to retrieve new gloves, the CNA did not perform hand hygiene before putting on clean gloves to continue care. The curtain was identified as a potentially contaminated surface. The CNA acknowledged after the incident that she should have used hand sanitizer before putting on new gloves, recognizing the curtain could be dirty. The resident involved was an elderly female with diagnoses including hypertension, hyperlipidemia, and vascular dementia, and was always incontinent of bowel and bladder. The resident's care plan required regular checks and assistance with toileting and incontinence care. Interviews with the DON and an LVN confirmed that facility policy and standard precautions require hand hygiene before and after glove use, and that the observed lapse was inconsistent with both facility policy and recent staff training. Review of the facility's hand hygiene policy further confirmed the expectation for hand hygiene before donning gloves and after glove removal.