F0880

D

Failure to Perform Hand Hygiene and Proper Glove Use During Incontinence Care

Bell Gardens, California Survey Completed on 02-11-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to implement its infection prevention and control program, specifically related to hand hygiene and glove use during incontinence care for one resident. The resident had diagnoses including muscle weakness and hypertension, lacked capacity to make decisions per a recent H&P, and was highly dependent on staff for activities of daily living according to the MDS, requiring extensive assistance for mobility, toileting, and personal hygiene. During an observed care episode, an LVN donned gloves without performing hand hygiene, opened the resident’s soiled diaper, cleaned the pubic area with a towel, turned the resident, and cleaned the buttocks with another towel, placing the used towels on the resident’s bed.

Without changing gloves or performing hand hygiene, the LVN then placed a clean diaper on the resident, covered the resident with a blanket, and touched the resident’s knees with the same contaminated gloves. In a concurrent interview, the LVN acknowledged not washing or sanitizing her hands before putting on gloves, not removing the used/dirty gloves prior to placing the clean diaper, and not performing hand hygiene after cleaning and before further contact with the resident. The LVN stated she should have washed or sanitized her hands prior to putting on gloves and before cleaning and touching the resident, and recognized that not doing so could lead to infections, including urinary and wound infections that could result in hospitalization. Review of the facility’s hand hygiene policy and hand hygiene table showed that staff are required to perform hand hygiene before applying and after removing PPE, including gloves, and before performing resident care procedures, which was not followed in this instance.