Failure to Perform Proper Hand Hygiene and Glove Changes During Perineal Care
Penalty
Summary
The deficiency involves the facility’s failure to establish and maintain an effective infection prevention and control program during perineal care for one resident. The resident was an adult female with multiple diagnoses including type 2 diabetes mellitus, lack of coordination, and muscle wasting and atrophy, and required substantial/maximal assistance with ADLs. Her care plan identified bowel and bladder incontinence and directed that her perineal area be cleaned with each incontinence episode. During an observation, CNA A washed her hands and donned clean gloves, then used the bed remote, removed the resident’s blanket and gown, and retrieved cleansing wipes without changing gloves or performing hand hygiene before beginning perineal care. The observation further showed that CNA A cleaned the resident’s perineal area, rolled the front of the brief, then turned the resident to her right side and cleaned visible bowel movement without changing gloves or performing hand hygiene between these tasks. In a subsequent interview, CNA A acknowledged she should have changed gloves and performed hand hygiene after touching the bedside remote and the resident’s surroundings, and again when moving from a clean area to a dirty area. The DON stated that CNA A should have removed contaminated gloves after touching the resident’s immediate surroundings and when moving from cleaning the perineal area to the gluteal area, and that the facility followed CDC hand hygiene guidelines. Review of the facility’s perineal care and hand hygiene policies showed they did not specify when hand hygiene should be performed, despite CDC guidance that hands should be cleaned before touching a patient, before moving from a soiled to a clean body site on the same patient, after touching a patient or their surroundings, after contact with blood or body fluids, and immediately after glove removal.
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