Failure to Follow Hand Hygiene, PPE, and Linen-Handling Practices
Penalty
Summary
The deficiency involves multiple failures to follow the facility’s infection prevention and control practices, particularly related to hand hygiene, glove use, handling of soiled linens, and adherence to enhanced barrier precautions. One resident with chronic kidney disease, knee pain, hypertension, and muscle weakness was found lying in bed on an incontinence pad and linens soiled with urine and blood, with additional bed linens on the floor. A CNA, already wearing gloves, removed the soiled incontinence pad and placed it on the floor, then continued to cover the resident with clean linens, adjust the bed controls, and hand the resident the call light while wearing the same soiled gloves. The CNA then placed the soiled linens and pad into a plastic bag taken from the resident’s trash bin, contrary to the DON’s expectation that staff remove gloves, perform hand hygiene between dirty and clean tasks, and avoid placing linens on the floor. Another resident with stage 4 chronic kidney disease, type 2 diabetes mellitus, severe morbid obesity, and polyneuropathy required extensive assistance with personal hygiene and toileting. During incontinence care, a CNA wore gloves while wiping urine from the resident’s buttocks and groin and tucking a soiled bedsheet under the resident, then applied a clean brief and cream to the buttocks without changing gloves. After removing one soiled glove, the CNA took a clean glove from her pocket and another from the bathroom, donned them without performing hand hygiene, and continued to apply cream to the groin, remove the soiled bedsheet, and finish securing the brief. The CNA then put on the resident’s socks and shorts while the resident remained on a urine-soiled mattress, placed a mechanical lift sling under the resident, removed gloves, and handled the trash bag with soiled linens and exited the room without performing hand hygiene, contrary to the facility’s hand hygiene policy and the DON’s stated expectations. Additional deficiencies were observed during medication administration and care of a resident on enhanced barrier precautions. A nurse administered insulin to one resident and then prepared and administered two types of insulin to another resident without performing hand hygiene before or after either medication pass. For a resident on enhanced barrier precautions with a central IV line, a nurse checked vital signs without gloves and without hand hygiene before or after, then prepared and administered oral and IV medications wearing only gloves and without performing hand hygiene. This was inconsistent with the facility’s hand hygiene policy, which requires alcohol-based hand rub before resident contact, between soiled and clean body sites, and after glove removal, and with the EBP posting on the resident’s door, which instructed staff to clean hands upon entering and leaving the room and to wear gown and gloves for high-contact care involving devices such as central lines.
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