Failure to Ensure CNA Competency in Hand Hygiene and Glove Use During Incontinent Care
Penalty
Summary
The deficiency involves the facility’s failure to ensure that certified nurse aides (CNAs) possessed and demonstrated appropriate infection control competencies, specifically hand hygiene and glove use, during incontinent care. Surveyors observed two CNAs (A and B) enter the room of Resident #8 without performing hand hygiene and immediately don gloves. They then conducted the entire incontinent care procedure without changing gloves, despite handling soiled items and then moving to clean tasks and clean items. Resident #8 had been recently admitted with diagnoses including chronic systolic heart failure, anemia, and osteoporosis. A Significant Change MDS assessment documented moderate cognitive impairment with a BIMS score of 10, a need for partial/moderate assistance with toileting hygiene, and continuous urinary and bowel incontinence. Her care plan, revised shortly before the observation, identified a UTI and included interventions to check for incontinence at least every two hours, indicating ongoing incontinence management needs. During interviews, both CNAs acknowledged they had received skills check-offs on hire, including perineal care and infection control, but each stated they believed they could continue using the same gloves as long as they were not visibly soiled with feces. They both recognized, when questioned, that gloves should be changed after handling dirty items and that failure to do so could result in cross-contamination. Facility leadership, including the ADON/IP, DON, and Administrator, stated that staff were trained on infection control, that hand hygiene should be performed before, during, and after care, and that gloves should be changed between dirty and clean tasks, confirming that the observed practices by CNAs A and B did not comply with facility policy and competency expectations for infection control.
We Help Long-Term Care Teams Stay Survey-Ready
We process and analyze inspection reports and plan of correction using AI to extract insights and trends so providers can improve care quality and stay ahead of compliance risks.