Failure to Perform Hand Hygiene and Change Gloves During Incontinence Care
Penalty
Summary
The deficiency involves the facility’s failure to maintain proper infection prevention and control practices during urinary incontinence care for one resident. The resident was an older female with Alzheimer’s disease, cerebrovascular accident, anxiety disorder, moderate cognitive impairment (BIMS score of 12), and a need for assistance with personal care. She was frequently incontinent of bladder. During an observed episode of urinary incontinence care, CNA A entered the resident’s room, performed hand hygiene, and donned gloves. CNA A then unfastened the resident’s brief and cleaned the front pubic area using several peri wipes. After cleaning the front pubic area, CNA A did not change gloves or perform hand hygiene before proceeding with the rest of the care. She assisted the resident onto her side, removed and discarded the soiled urine-saturated brief, and cleaned the resident’s buttocks with peri wipes, still without changing gloves or performing hand hygiene. CNA A then placed a clean brief under the resident, repositioned and covered her, and lowered the bed, continuing to use the same gloves. She gathered dirty clothes and trash, then removed her gloves and washed her hands only at the end of care. In interviews, CNA A and the DON both acknowledged that facility policy and expected practice required hand hygiene and glove changes when moving from a contaminated to a clean body site and between dirty and clean tasks, consistent with the facility’s Handwashing/Hand Hygiene policy dated August 2019.
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