Failure to Change Gloves and Perform Hand Hygiene During Incontinence Care
Penalty
Summary
Surveyors identified a deficiency in infection prevention and control related to incontinence care for one resident. During an observation, a CNA provided incontinence care to a resident wearing a urine-saturated brief. While wearing a single pair of gloves, the CNA pulled down the saturated brief, used peri wash and disposable wipes to cleanse the resident’s front perineal area, retracted the foreskin and cleaned the glans, and wiped the groin. The CNA then turned the resident, removed the soiled brief and linens, and, without changing gloves or performing hand hygiene, arranged and rolled a clean fitted sheet, pad, and brief under the resident. The CNA positioned the resident on his back and fastened the clean brief, still using the same gloves. The CNA then continued additional resident care and environmental tasks without changing gloves or performing hand hygiene. With the same gloves, the CNA obtained assistance to boost the resident up in bed, put a clean gown on the resident, covered him with a clean top sheet and personal blanket, adjusted the resident’s pillows, tidied items on the overbed table, and removed the garbage. The CNA left the room carrying a bag of soiled linens while still wearing the same gloves used throughout the entire procedure. The DON later stated that during incontinence care, gloves should be changed after removing dirty briefs and linens and after wiping soiled areas, and that hands should be sanitized, which was also reflected in the facility’s Incontinent and Perineal Care Policy requiring glove changes and handwashing at specified points in the procedure.
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