F0880

D

Failure to Follow Hand Hygiene and Linen Handling Practices During Perineal Care

Anderson, Indiana Survey Completed on 02-09-2026

Penalty

No penalty information released

Summary

The deficiency involves a failure to implement proper infection prevention and control practices during incontinence and personal care for one resident. During an observed care episode, a CNA and a QMA donned gloves and uncovered the resident, whose incontinence brief was soiled. The QMA provided perineal care, removed the soiled brief from under the resident, retrieved a trash can, and disposed of the brief, but did not change gloves or perform hand hygiene after completing perineal care. With the same gloves still on, the QMA then assisted the resident with dressing, helped the resident sit on the side of the bed, transferred the resident into a wheelchair, and handled the resident’s oxygen tubing and nasal cannula, placing it on the resident’s face and nose.

During the same care episode, while the QMA and CNA were assisting the resident, the CNA placed a soiled bath blanket onto the carpeted floor while making the resident’s bed, despite a facility policy stating that soiled linen should not be placed on furniture or the floor. The CNA later stated the blanket was only slightly soiled and that she would not normally place soiled linens on the floor, and the QMA acknowledged he had forgotten to change gloves and would normally do so after providing perineal care. The resident involved had diagnoses including Parkinson’s disease and dementia, was moderately cognitively impaired per a recent MDS, was dependent for toileting hygiene, required substantial to maximal assistance with personal hygiene, and was always incontinent of bladder and frequently incontinent of bowel. During the exit conference, the Executive Director indicated there was no facility policy specifically related to changing gloves after providing perineal care.