Failure to Perform Hand Hygiene and Glove Change Between Dirty and Clean Tasks
Penalty
Summary
The deficiency involves a failure to follow infection control procedures during personal care for one resident. Record review showed the resident had peripheral vascular disease, a history of stroke, and hemiplegia/hemiparesis. During an observation, the resident was standing at the bedside after using a bedside commode, with swim trunks around the lower legs and a gait belt secured at the waist for stability. One CNA stood in front of the resident holding the gait belt to assist with stability, while another CNA, who was wearing gloves, performed perineal care. The gloved CNA cleansed the resident’s buttocks and anal area with a wet washcloth and then used a dry washcloth to pat the area dry. After completing this contaminated task, the CNA did not change gloves or perform hand hygiene before proceeding to pull up the resident’s swim trunks, which constituted a clean task. In an interview, the CNO and ICP stated that staff were expected to perform hand hygiene and change gloves when moving from a dirty task to a clean task, and that the CNA should have changed gloves prior to touching the resident’s clothing. The facility’s hand hygiene policy required hand hygiene before moving from a contaminated body site to a clean body site during resident care.
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