Failure to Perform Hand Hygiene and Glove Changes During Perineal Care
Penalty
Summary
The deficiency involves the facility’s failure to ensure proper infection prevention and control practices during incontinent care for one resident. The resident was an elderly female with hemiplegia/hemiparesis, a history of sepsis, and kidney failure, who was severely cognitively impaired per a BIMS score of 00 and required maximal assistance with transfers, toileting, and bathing. Her comprehensive care plan included interventions for risk of pressure ulcers and other skin issues, including checking for incontinence during rounds and providing care as needed. During an observation of perineal care, the nursing assistant providing care did not perform hand washing, hand hygiene, or change gloves between cleaning soiled areas and handling a clean brief or redressing the resident. In a subsequent interview, the nursing assistant acknowledged that she should have changed gloves after cleaning the perineal area and before opening the new brief, and again after cleaning the resident’s bottom and before touching the new brief, and admitted she did not perform any hand hygiene throughout the incontinent care. The DON stated that staff were expected to follow the facility’s infection control policies and procedures and noted that cross contamination could contribute to infection. The facility’s Perineal Care Policy specified that staff were to wash hands and wear gloves, following Standard Precautions if contact with blood or body fluids was likely, as part of the beginning steps of the procedure. The observed care did not comply with these established policy requirements for hand hygiene and glove use.
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