Failure to Perform Hand Hygiene During Incontinence Care
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program related to hand hygiene during incontinence care for Resident #374. The resident, admitted on 11/27/23, had multiple medical diagnoses including unspecified dementia (moderate with psychotic disturbance), moderate protein-calorie malnutrition, essential hypertension, hyperlipidemia, anxiety, depression, atrial fibrillation, history of transient ischemic attack and cerebral infarction without residual deficits, dysarthria and anarthria, low back pain, and irritable bowel syndrome with constipation. A quarterly MDS dated 01/09/26 documented a BIMS score of 6/15 and dependence on staff for toileting hygiene. The care plan noted frequent bladder and bowel incontinence, goals for meeting toileting needs and maintaining grooming and freedom from odors, and interventions including incontinence care with each episode, application of moisture barrier, and staff assistance with all ADLs including toileting hygiene. On observation, CNA #313 and RN #255 provided perineal care to Resident #374. CNA #313 pulled the curtain, performed hand hygiene, donned PPE, prepared wash basins, then again performed hand hygiene and applied clean gloves before removing the resident’s brief and performing perineal care. After washing and drying the perineal area, CNA #313, with assistance from RN #255, turned the resident, washed and dried the buttocks, applied barrier cream, and placed a new brief. Without removing gloves or performing hand hygiene, CNA #313 then handed the resident her baby dolls using the same gloves that had been used during incontinence care. In a subsequent interview, CNA #313 confirmed not performing hand hygiene and not changing gloves during the incontinence care. Review of facility policies on Hand Hygiene and Perineal Care confirmed that staff are required to perform hand hygiene when moving from a contaminated body site to a clean body site, after handling items potentially contaminated with body fluids, and to remove gloves and perform hand hygiene after perineal care.
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