Failure to Perform Hand Hygiene and Change Gloves During Incontinence Care
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program related to hand hygiene and glove use during incontinence care. The facility’s Standard Precautions policy required staff to perform hand hygiene immediately after contact with any resident item that may be contaminated, and CDC guidelines required hand decontamination when moving from a contaminated body site to a clean body site during patient care. During an observation, two CNAs entered a resident’s room to perform incontinence care, removed the resident’s soiled diaper, and wiped the resident’s buttocks and perineal area. After completing care of the contaminated area, the CNAs did not change their gloves or perform hand hygiene before proceeding to place a clean diaper on the resident, roll and reposition the resident, place a clean draw sheet, and cover the resident with clean linen. One CNA then opened and closed the resident’s dresser door and raised the head of the bed while still wearing the contaminated gloves, without performing hand hygiene or changing gloves. In subsequent interviews, both CNAs acknowledged they had not changed gloves or performed hand hygiene after removing the soiled diaper and stated they should have done so. The DON confirmed that the CNAs should have changed gloves and performed hand hygiene when moving from a contaminated body area to a clean body area during incontinence care.
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