F0880

E

Inadequate Hand Hygiene and Glove Use During Care and Medication Administration

Ganado, Texas Survey Completed on 02-25-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to maintain an effective infection prevention and control program during personal care and medication administration for multiple residents. For one resident with epilepsy, Down syndrome, Alzheimer’s disease, type 2 diabetes mellitus, hypothyroidism, and hyperlipidemia, who was severely cognitively impaired, dependent on staff for care, and always incontinent of bowel with an indwelling catheter, two CNAs provided incontinent care without fully sanitizing their hands. During care, both CNAs used hand sanitizer but did not sanitize between their fingers, contrary to the facility’s infection control policy, which requires covering all surfaces of the hands and fingers when performing hand hygiene.

Another deficiency occurred during incontinent care for a cognitively intact resident with type 2 diabetes mellitus, hypertension, chronic kidney disease, hypothyroidism, and hyperlipidemia, who was dependent on staff for toileting hygiene, had an indwelling catheter, and was always incontinent of bowel. While removing a soiled brief, a CNA touched the soiled brief and then, without changing gloves or performing hand hygiene, handled and applied a clean brief to the resident. This action conflicted with the facility’s infection control policy, which requires hand hygiene after handling soiled items such as linens and catheter-related supplies.

A third incident involved a resident with convulsions, hypothyroidism, hyperlipidemia, dementia, hypertension, and obstructive and reflux uropathy, who was severely cognitively impaired and always incontinent of bowel and bladder. During incontinent care, a CNA washed her hands and donned gloves, then used the gloved hand to touch the bed remote to adjust the bed, which she later acknowledged was considered dirty. She did not change gloves or sanitize her hands before proceeding with care and did not sanitize her hands between glove changes, despite facility policy requiring hand hygiene after removing gloves and after handling soiled or used items in the resident’s environment.

The final deficiency involved medication administration for a resident with hemiplegia, type 2 diabetes mellitus, hyperlipidemia, hypertension, and dementia, who required extensive to total assistance with activities of daily living. While administering eye drops, a medication aide wore gloves and used the same gloved hand to touch the medication cart key, the medication cart, the resident’s side table, and the bed remote, all of which she later identified as dirty or contaminated surfaces. She did not change gloves or sanitize her hands before touching the resident’s face and administering the eye drops. This sequence of actions occurred despite the facility’s eye ointment administration policy requiring handwashing and donning gloves in connection with medication administration and the broader infection control expectations described by the DON.