Failure to Follow Hand Hygiene and Enhanced Barrier Precautions During Incontinence Care
Penalty
Summary
The deficiency involves the facility’s failure to follow its own infection prevention and control policies, including hand hygiene, glove use, and enhanced barrier precautions (EBP), during incontinence care for two residents. Facility policies required perineal care to promote cleanliness, comfort, and infection prevention, and specified that hand hygiene must be performed before moving from a contaminated to a clean body site and after contact with bodily fluids. The EBP policy required gown and glove use for high-contact care activities such as changing linens, changing briefs, providing hygiene, and wound care, and the hand hygiene policy stated that glove use does not replace hand hygiene and that hand hygiene must be performed before donning and immediately after removing gloves. One resident, admitted with hemiplegia and hemiparesis following cerebral infarction and needing assistance with personal care, had a BIMS score indicating moderate cognitive impairment and was on EBP for potential infection related to wounds. An EBP sign on the resident’s door directed staff to wear gloves and a gown for high-contact care activities. During observed incontinence care, a CNA performed hand hygiene and donned gloves but did not initially wear a gown, only putting one on after being instructed by the Regional Risk Consultant. The CNA did not perform hand hygiene during glove changes and exited the room while still wearing the gown to obtain a clean sheet from a linen cart in the hallway, then disposed of soiled linens and a brief in hallway receptacles without bagging them. In interviews, the CNA acknowledged not sanitizing hands between glove changes and not wearing a gown at the beginning of care, while the ADON and DON stated that staff are expected to wear gowns and gloves for EBP residents, perform hand hygiene with each glove change, have supplies in the room, and not go in and out of rooms while gowned or handle hallway linen carts while wearing gowns. For another resident with diagnoses including cerebrovascular insufficiency, hemiplegia, vascular dementia, and major depressive disorder, and who was always incontinent of bowel and bladder per the MDS, a separate incontinence care observation showed additional failures in infection control. A CNA donned gloves before entering the room and then provided the entire episode of incontinence care using the same pair of gloves. The CNA wrapped a urine-soiled brief, applied barrier cream to the perineal area, and placed a new brief on the resident without changing the contaminated gloves or performing hand hygiene between tasks. In a subsequent interview, the CNA confirmed that gloves were not changed during the care episode and that handwashing and glove application occurred only before entering the room.
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