Failure to Follow Hand Hygiene and Aseptic Technique During Peri-Care and Wound Care
Penalty
Summary
The deficiency involves the facility’s failure to implement and follow its infection prevention and control program, specifically related to hand hygiene, glove use, and prevention of cross-contamination during resident care. For one resident with multiple sclerosis, neuromuscular bladder dysfunction, quadriplegia, and an indwelling catheter, two CNAs entered the room to perform catheter and peri-care. Both CNAs initially performed hand hygiene and donned PPE. One CNA removed the resident’s brief while the other provided catheter care and then cleaned the resident’s backside after bowel incontinence. After providing this care, the CNA obtained a clean brief and placed it under the resident without performing hand hygiene or changing gloves. The same CNA then adjusted the resident’s urinary catheter and hung the catheter bag on the side of the bed, again without performing hand hygiene or changing gloves. The CNA obtained a graduate, drained the catheter bag, emptied the graduate into the toilet, flushed the toilet, touched the resident’s sink, and turned on the water to rinse the graduate, all while wearing the same soiled gloves. Only after these tasks did the CNA remove gloves and perform hand hygiene. The CNA did not sanitize any of the room surfaces that had been touched with soiled gloves. Staff interviews, including with CNAs, the DON, and the Administrator, confirmed that the facility’s expectation was that staff perform hand hygiene and change gloves when moving from dirty to clean surfaces to prevent cross-contamination. A second deficiency occurred during wound care for another resident with cellulitis of the left lower limb, non-pressure chronic ulcers of both lower legs, and open foot lesions. An LPN entered the room to perform wound care on a left leg wound that had an odor, visible brownish-yellow drainage through the gauze wrap, and drainage on a bed pad under the leg. The LPN placed clean dressing supplies on a clean barrier, then applied gloves without hand hygiene, removed the resident’s shoe and sock, used scissors from a pocket to cut off the soiled dressing, and then placed the soiled scissors on the clean barrier next to clean supplies. The LPN removed gloves, did not perform hand hygiene, donned new gloves, and began cleansing the wounds, repeatedly reaching into a bulk bag of gauze and handling clean supplies without changing gloves or performing hand hygiene. The LPN placed the used wound cleanser bottle and clean gauze roll back on the designated clean barrier after touching them with contaminated gloves, briefly acknowledged not remembering all the steps, then removed gloves, performed hand hygiene, donned new gloves, and used the previously contaminated gauze roll to wrap the wound. The LPN then handled the resident’s sock and shoe, placed the leg back on the soiled bed pad, exited the room, removed gloves, used hand sanitizer, and left the contaminated bulk gauze bag, scissors, and wound cleanser on top of the treatment cart. Interviews with CNAs, the DON, and the Administrator confirmed expectations that reusable items used for multiple residents be sanitized before and after use and that soiled hands not be placed into bulk supplies.
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