Failure to Perform Hand Hygiene and Change Gloves After Incontinence Care
Penalty
Summary
A deficiency occurred when a certified nursing assistant (CNA) failed to follow infection prevention and control practices during incontinence care for one resident. The resident was an adult female with multiple medical conditions, including neuromyelitis optica, difficulty walking, muscle and coordination disorders, cognitive communication issues, depression, lung findings, cervical spinal stenosis, anemia, edema, hyperlipidemia, tremor, aphasia, anxiety, dysthymic disorder, and kidney/ureter disorder. Her BIMS score indicated moderate cognitive impairment, but she was alert, oriented, groomed, able to make her needs known, and observed lying in bed with the call light within reach. The resident reported that she had been pressing the call light for help to be changed, that a CNA had said she would return but did not, and that she still needed to be changed. The CNA later stated she had last changed the resident around 9:00 a.m. When the CNA entered the room to provide incontinence care, she donned gloves and proceeded with the care. After completing the incontinence care, she placed the soiled incontinence brief in a plastic bag and then, without changing gloves or performing hand hygiene, moved the bedside table over the resident and adjusted the resident’s clothing and bed. She then went to the glove box, removed the soiled gloves, and put on clean gloves without performing hand hygiene, and proceeded to adjust the resident in bed and prepare to feed her, again without completing hand hygiene. The CNA later acknowledged she should have removed gloves and washed her hands after incontinence care and should not have touched anything with dirty gloves. The facility’s infection prevention nurse and assistant DON both stated that incontinence care requires glove use and hand hygiene before and after care, and that staff should not touch resident items or equipment with soiled gloves. Facility policy and CDC hand hygiene guidance, as well as the CNA job description, require hand hygiene before and after resident care and emphasize that gloves are not a substitute for hand hygiene.
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