Improper Hand Hygiene and Glove Use During Perineal Care
Penalty
Summary
The deficiency involves the facility’s failure to ensure proper infection prevention and control practices during incontinent and perineal care for one resident. The resident was an elderly female with encephalopathy, severely impaired cognition (BIMS score of 7), and total dependence on staff for toileting hygiene, with continuous bowel and bladder incontinence. During an observation of perineal care, the CNA entered the room and washed her hands, then donned gloves and unfastened the resident’s brief to clean the peri-area. After cleaning the peri-area, the CNA rolled the resident, removed the soiled brief, and disposed of it in a trash bag while still wearing the same contaminated gloves. The CNA then removed those gloves and applied new gloves without performing hand hygiene. She proceeded to clean the resident’s rectal area and, without removing those now-contaminated gloves, retrieved a clean draw sheet and placed it under the resident along with a clean brief, then repositioned and refastened the brief while still wearing the same gloves used for rectal care. Hand hygiene was only performed after all care was completed, when the CNA removed her gloves, tied the trash bag, and washed her hands before exiting the room. In an interview, the CNA acknowledged she did not perform hand hygiene between glove changes, was unsure if she changed gloves between cleaning the rectal area and handling clean items, and stated she knew she was supposed to use sanitizer when changing gloves. Facility policy required hand hygiene before moving from a contaminated body site to a clean body site and after removing gloves, which was not followed in this instance.
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.