Failure to Follow Hand Hygiene and PPE Requirements During Incontinence and Wound Care
Penalty
Summary
The deficiency involves the facility’s failure to ensure staff followed appropriate infection prevention and control practices during incontinence care for one resident and wound care for another. For the first resident, who had multiple medical conditions including vascular dementia, orthopedic aftercare needs, and complete dependence on staff for ADLs and continence care, surveyors observed incontinence care being performed by an LPN and a CNA. After removing the resident’s soiled brief and performing perineal care, the CNA removed her soiled gloves and immediately donned clean gloves without performing hand hygiene before obtaining and applying clean clothing. The LPN also did not change gloves or perform proper hand hygiene between handling the soiled brief and proceeding with the clean brief. Both staff members later confirmed they had not applied clean gloves or used proper hand hygiene between the soiled and clean portions of the care. The second deficiency involved wound care for another resident who was cognitively intact, independent with ADLs, and had a Stage III pressure ulcer on the right lateral ankle with care orders that included cleansing with normal saline, applying Skin-Prep, and covering with a bordered foam dressing. This resident had an active order for enhanced barrier precautions (EBP), and signage indicating EBP was posted on the door. During observed wound care, the LPN sanitized the bedside table, placed a barrier, gathered supplies, performed hand hygiene, and donned clean gloves, but did not don any additional PPE required under EBP before starting the procedure. The LPN removed the soiled dressing, discarded it, changed gloves with hand hygiene in between, cleansed the wound, applied Skin-Prep and a new foam dressing, and completed the task without ever using the additional PPE indicated by the EBP signage and facility policy. The facility’s own undated standard precautions policy required hand hygiene before and after direct contact with a resident’s skin, after contact with body fluids or excretions, and after glove removal. CDC guidance on hand hygiene and glove use, cited in the report, states that gloves are not a substitute for hand hygiene and that staff should change gloves and perform hand hygiene when moving from a soiled body site to a clean body site on the same patient. The DON confirmed that the facility had a policy requiring PPE use for wound care. The observed failures in hand hygiene and PPE use for these two residents were identified as deficiencies during a complaint investigation.
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