Failure to Follow Hand Hygiene and Glove Use Protocol During Incontinence Care
Penalty
Summary
The deficiency involves the facility’s failure to implement infection prevention and control measures during incontinence care for one resident. The resident had diagnoses including muscle weakness and hypertension, fluctuating capacity to understand and make decisions, and required substantial to maximal assistance for bed mobility and was dependent for toileting hygiene, lower body dressing, and transfers. During an observation in the resident’s room, a CNA wearing gloves opened the resident’s soiled incontinence brief, cleaned the pubic area, then used the bed remote control to reposition the bed without changing gloves or performing hand hygiene. The CNA then turned the resident to the left side, cleaned the buttocks and buttocks fold, removed the soiled brief, and applied a clean brief, again without changing gloves or performing hand hygiene. After completing the incontinence care, the CNA left the resident’s room still wearing the same soiled gloves and without performing hand hygiene in order to obtain a clean gown for the resident. In an interview, the CNA stated she did not realize she had not changed her gloves because she was trying to finish the incontinence care quickly. The Infection Prevention Nurse stated that staff should change gloves and perform hand hygiene when moving from dirty to clean areas, and that failure to do so could lead to the spread of germs and place residents at risk for infections. Review of the facility’s PPE policy indicated gloves are to be used once, discarded in the appropriate receptacle in the room, and that hands are to be washed before and after removing gloves. The facility’s hand hygiene policy identified hand hygiene as the primary means to prevent the spread of infections and required hand hygiene after contact with body fluids and before donning and after doffing PPE, as well as upon entering and exiting a resident room.
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