Failure to Perform Hand Hygiene and Change Gloves During Incontinence Care
Penalty
Summary
The deficiency involves a failure to maintain proper infection prevention and control practices during incontinence care for one resident. The resident was an older female with diagnoses including hypertension, a left femoral neck fracture, muscle wasting and atrophy, and generalized muscle weakness. Her Quarterly MDS showed a BIMS score of 15, indicating intact cognition, and she was frequently incontinent of bladder. During an observation of incontinence care, a CNA entered the resident’s room, performed hand hygiene, and donned gloves. He unfastened the resident’s brief and cleaned the front pubic area with peri wipes, then assisted her onto her left side, removed and discarded the soiled brief, and cleaned the buttocks area, during which a medium bowel movement was present. After completing cleaning of the soiled areas, the CNA did not change gloves before proceeding to place a clean brief under the resident, reposition her onto her back, fasten the clean brief, cover her, and lower the bed. He then gathered dirty clothes and trash, removed his gloves, performed hand hygiene, and exited the room. In an interview, the CNA acknowledged he was supposed to change gloves and perform hand hygiene each time he moved from a dirty to a clean area during care and stated he did not do so because he was nervous about being observed. The DON confirmed that staff were expected to perform hand hygiene before and after care and to change gloves and perform hand hygiene between dirty and clean tasks, as the hands are considered dirty after cleaning the resident. The facility’s hand hygiene policy required hand hygiene after contact with soiled or contaminated articles and after removal of gloves.
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