F0880

D

Failure to Perform Hand Hygiene and Change Gloves Between Dirty and Clean Tasks

New Brighton, Minnesota Survey Completed on 03-20-2026

Penalty

No penalty information released

Summary

The deficiency involves staff failure to follow established hand hygiene and glove-use practices during incontinence care for one resident. During an observation, a nursing assistant removed a soiled brief, wiped the resident’s perineum and buttocks, discarded the soiled brief and wipes, and then continued with clean tasks without removing gloves or performing hand hygiene. While still wearing the same gloves used for peri care, the nursing assistant placed a clean brief under the resident, applied barrier cream to the perineum, fastened the brief, positioned the draw sheet, assisted with repositioning the resident, adjusted bedding, clipped the call light to the bedding, and repositioned the resident’s oxygen tubing in her nostrils before finally removing gloves and performing hand hygiene.

The resident involved had an admission MDS indicating diagnoses of heart failure and respiratory failure, severe cognitive impairment, frequent bowel and bladder incontinence, and dependence on staff for all cares and transfers, and was Hmong speaking. Her care plan and NA guide documented the need for assistance with bed mobility, transfers, and incontinence care every 2–3 hours. A grievance form documented that an LPN was made aware that staff were not changing gloves between changing the resident’s brief and adjusting her oxygen tubing. A family member reported observing staff not changing gloves after peri care via a camera in the resident’s room. Facility staff, including the nursing assistant, LPN, and DON, each stated in interviews that gloves should be changed between dirty and clean tasks and that hand hygiene should be performed before donning and after removing gloves, consistent with the facility’s Handwashing Policy, which requires handwashing after changing incontinent products and before and after glove use.