Improper Glove Use and Hand Hygiene During Incontinent Care
Penalty
Summary
The deficiency involves a failure to ensure proper infection prevention and control practices during incontinent care for Resident #95. The resident was admitted with diagnoses including hemiplegia and hemiparesis following a stroke and urinary incontinence, had intact cognition, required setup assistance for eating, moderate assistance for bed mobility, and was totally dependent for toileting, with toileting transfers not attempted due to medical or safety concerns. The care plan indicated that two helpers were required for toileting hygiene assistance. During an observed episode of incontinent care, a CNA entered the room, provided privacy, gathered supplies, donned a single pair of gloves, removed the blankets, untaped the soiled incontinent brief, and tucked the ends between the resident’s upper thighs. The CNA then used moistened wipes to cleanse the anterior perineal area, using the same area of a wipe for multiple strokes over different skin folds. After completing anterior perineal hygiene, the CNA assisted the resident to her left side, removed and discarded the soiled brief, and continued perineal care. The CNA used a disposable wipe to clean the buttocks from the outer area toward the inner gluteal folds, including wiping from the top of the intergluteal cleft to and past the rectal area, and also wiping from the vaginal area to the rectum, making several swipes with the same wipe before discarding it. Without changing gloves or performing hand hygiene, the CNA then handled a clean incontinent brief, placing and adjusting it under the resident, and subsequently dispensed barrier cream onto the same gloved hand and applied it to the inner thighs. The CNA removed the gloves, failed to perform hand hygiene, assisted with blanket placement, tied and removed the trash bag, and used the soiled linen closet handle before leaving the area. In a subsequent interview, the CNA confirmed that she used one pair of gloves for the entire task and did not perform hand hygiene before applying the clean brief or leaving the room. The DON stated that the staff member should have changed gloves and washed hands after removing the soiled brief, applied new gloves before applying the clean brief, and performed hand hygiene prior to leaving the room.
We Help Long-Term Care Teams Stay Survey-Ready
We process and analyze inspection reports and plan of correction using AI to extract insights and trends so providers can improve care quality and stay ahead of compliance risks.