Failure to Perform Hand Hygiene Between Glove Changes During Catheter and Incontinence Care
Penalty
Summary
The deficiency involves the facility’s failure to ensure staff performed hand hygiene according to current standards of practice during catheter and incontinence care for three cognitively intact residents. One resident with Guillain-Barré syndrome, neuromuscular bladder dysfunction, and urinary retention had an indwelling Foley catheter with care ordered every shift. During observed catheter care, the CNA changed gloves multiple times after cleaning the insertion site, washing the tubing, and drying the area, but did not perform hand hygiene between glove changes. In a subsequent interview, the CNA acknowledged she should have performed hand hygiene between glove changes and stated it slipped her mind. Another resident with chronic kidney disease, heart failure, obesity, osteoarthritis, osteoporosis, history of falls, and myoclonus required two-person assist for toileting. Two CNAs were observed providing incontinence care, including washing and drying the peri area and buttocks, and changing gloves after each step, but they did not perform hand hygiene between glove changes. Both CNAs later stated they had hand sanitizer in their pockets but either forgot to use it or were unsure why they did not. A third resident with benign prostatic hypertrophy and hydronephrosis with renal and ureteral calculus had an indwelling Foley catheter with orders for catheter care every shift. Two CNAs provided catheter care, changing gloves after cleaning the insertion site, tubing, and buttocks, and after drying, but did not perform hand hygiene between glove changes; they stated they did not have hand sanitizer in the room. The facility’s handwashing/hand hygiene policy states that hand hygiene is the primary means to prevent the spread of infections, that products and supplies shall be readily accessible and convenient for staff use, and that hand hygiene is the final step after removing and disposing of PPE.
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