F0880

D

Infection Control Lapses During Incontinence Care and Medication Handling

Newark, Ohio Survey Completed on 03-05-2026

Penalty

No penalty information released

Summary

The deficiency involves failure to follow infection prevention and control practices during incontinence care for one resident. The resident was admitted with multiple diagnoses including cerebral infarction, hypertension, dementia, anorexia, abnormalities of gait and mobility, and urinary incontinence. The admission MDS showed severe cognitive impairment with a BIMS score of six, and the resident required supervision with toileting hygiene, being occasionally incontinent of bladder and always incontinent of bowel. The care plan directed staff to check and change the resident approximately every two to three hours and as needed for incontinence. During an observed incontinence care episode, a CNA washed his hands and donned gloves, then, while wearing the same gloves, opened bags of clean linen, placed a clean towel on the bedside table, accepted uncovered wash basins from an LPN, filled the basins with water, placed clean washcloths in them, and moved the bedside table closer to the bed.

Without changing gloves after handling these items, the CNA proceeded to perform peri-care on the resident. Only after completing peri-care did the CNA remove his gloves and wash his hands, then don new gloves to place an incontinence brief and pull up the resident’s pants, followed by glove removal and handwashing. In a subsequent interview, the CNA confirmed that he had touched multiple items, including the basins and bedside table, before performing peri-care without changing gloves or re-washing his hands. The LPN present verified that the CNA did not change his gloves after touching multiple items prior to providing peri-care. These actions were inconsistent with the facility’s Handwashing/Hand Hygiene policy, which requires hand hygiene before and after direct contact with residents, and with the facility’s infection control policies intended to prevent transmission of infections.

A second deficiency involved failure to handle medication in a sanitary manner for another resident. This resident had multiple diagnoses including spinal stenosis, anxiety disorder, mild cognitive impairment, need for assistance with personal care, muscle weakness, cognitive communication deficit, dysarthria and anarthria, asthma, dementia, hypertension, hyperlipidemia, anemia, and osteoarthritis. The quarterly MDS indicated moderate cognitive impairment with a BIMS score of eleven and no psychosis, behavioral issues, or rejection of care. The resident had an order for Losartan Potassium 50 mg by mouth in the morning for hypertension. During observed medication preparation, an RN removed the Losartan pill from its individual container by popping the back, causing the pill to fall onto the medication cart. The RN then picked up the pill with bare fingers and placed it into the medication cup with the resident’s other oral medications, which were then administered and swallowed by the resident. In an interview, the RN confirmed she picked up the pill with bare fingers and stated she should have used a glove, contrary to the facility’s Administering Medications policy requiring adherence to infection control procedures during medication administration.