Failure to Perform Hand Hygiene Between Glove Changes During Incontinence Care
Penalty
Summary
The deficiency involves failure to follow the facility’s infection prevention and control and hand hygiene policies during incontinence care for one resident. The facility’s Infection Prevention and Control Program Description policy requires implementation of control measures and precautions, including hand hygiene, and the Hand Hygiene policy requires all staff to perform proper hand hygiene consistent with accepted standards of practice. The resident involved had diagnoses including contractures of both hands, UTI, and muscle weakness, with a BIMS score indicating moderately impaired cognition, and was care planned as bowel and bladder incontinent with staff responsible for cleaning the perineal area and changing briefs and clothing as needed after incontinence episodes. During observed incontinence care, a CNA did not perform hand hygiene between glove changes. The CNA acknowledged that she failed to sanitize her hands after removing used gloves and before donning a new pair and stated she should have done so. The SDC and DON both stated in interviews that staff are expected to wash or sanitize hands between glove changes and that failure to do so could result in spread of germs, cross-contamination, or infection to residents. These observations and interviews showed that staff actions during incontinence care did not comply with the facility’s established hand hygiene and infection control policies.
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