Failure to Perform Hand Hygiene During Incontinent Care
Penalty
Summary
The deficiency involves the facility’s failure to ensure proper hand hygiene during incontinent care, as required by its infection prevention and control program and hand hygiene policy. A male resident, admitted with intervertebral disc degeneration of the lumbar region and documented to need staff assistance for toileting due to an ADL self-care performance deficit, received incontinent care from a CNA. During this care, after the CNA cleaned feces from the resident’s rectal area, she removed the glove from her right hand and immediately donned a clean glove on that hand without performing hand hygiene. She did not change the glove on her left hand and then proceeded to place a clean brief on the resident and assist with transferring him from bed to chair. In a subsequent interview, the CNA acknowledged that she did not sanitize her hands during perineal care and confirmed she only changed the glove on her right hand after cleaning the rectal area, explaining she had not anticipated needing to perform incontinent care and was not prepared. The ADON stated she expected staff to perform hand hygiene when providing incontinent care and recognized that failure to do so could increase residents’ risk for infections. The Resource RN similarly stated she expected staff to follow policy and perform hand hygiene, especially when moving from dirty to clean tasks, and that residents could get an infection if hand hygiene was not performed. The facility’s hand hygiene policy, dated 10/2022, requires use of alcohol-based hand rub or soap and water before moving from a contaminated body site to a clean body site during resident care and after removing gloves, which was not followed in this incident.
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