Failure to Perform Hand Hygiene and Glove Change During Incontinent Care
Penalty
Summary
The deficiency involves the facility’s failure to maintain an effective infection prevention and control program during incontinent care for one resident. The resident was an older female with diagnoses including congestive heart failure, gait and mobility abnormalities, chronic pulmonary edema, Type 2 diabetes mellitus, muscle weakness, and lack of coordination. A comprehensive MDS showed she had moderately impaired cognition with a BIMS score of 10, was dependent on staff for toileting, and required maximum assistance for showering and bathing. Her care plan documented a self-care deficit and the need for staff assistance with toileting. On the observed date and time, two CNAs entered the resident’s room to provide incontinent care, washed their hands, and applied gloves. During the care, both CNAs removed the resident’s soiled brief but did not change their soiled gloves or perform hand hygiene before applying barrier cream. In subsequent interviews, both CNAs acknowledged they were supposed to remove soiled gloves and perform hand hygiene between steps of perineal care and stated they failed to do so because they forgot or were nervous. The DON and Administrator both confirmed that facility expectations and policy required hand hygiene between glove changes and changing soiled gloves prior to applying barrier cream, and that these practices were important to prevent urinary tract infections, sepsis, and the spread of disease. Facility policy on perineal care required doffing and discarding visibly soiled gloves and performing hand hygiene before and after glove use.
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