F0880

D

Failure to Perform Proper Hand Hygiene During Peri Care

Perry, Iowa Survey Completed on 01-08-2026

Penalty

No penalty information released

Summary

Surveyors identified a deficiency in the facility’s infection prevention and control program related to improper hand hygiene during incontinence (peri) care for one resident. The resident had diagnoses including Alzheimer’s disease, arthritis, hip fracture, and depression, with a BIMS score of 00 indicating severe cognitive impairment. During an observation of peri care, two CNAs performed hand hygiene before donning gloves and enhanced barrier precautions, then removed the resident’s pants and soiled brief. One CNA cleansed the front perineal area, and both CNAs then turned the resident to cleanse the back side. One CNA removed the soiled brief and bed pad and placed a clean brief and bed pad under the resident, after which the resident was rolled and the clean brief and pad were put in place.

Throughout this process, both CNAs continued to perform multiple care tasks without appropriate glove changes and hand hygiene as outlined in the facility’s peri care audit protocol. After completing cleansing and brief changes, they pulled up the resident’s pants, applied a mechanical lift sling under the resident while still wearing soiled gloves, and only then changed gloves without performing hand hygiene. They then applied new gloves and used the mechanical lift to transfer the resident to a wheelchair, placed leg pedals, a blanket, and combed the resident’s hair, again without changing gloves or performing hand hygiene during these steps. The facility’s peri care audit instructions specified multiple points at which gloves should be removed and hand hygiene performed during peri care, and the DON stated she would expect staff to change gloves and perform hand hygiene while performing peri care. One CNA later acknowledged she should have changed gloves and performed hand hygiene during the peri care process.