Failure to Perform Hand Hygiene After Incontinence Care
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program related to hand hygiene during incontinence care for Resident #71. Resident #71 was admitted on 12/27/23 with diagnoses including essential hypertension, type II diabetes mellitus without complications, osteoarthritis, contractures of both knees, need for assistance with personal care, unspecified dementia, and other cognitive symptoms, and had a BIMS score of 10. The resident’s MDS dated 01/03/26 documented that she was dependent on staff for toileting hygiene. On 03/04/26 at 11:50 A.M., during observed incontinence care, CNA #97 completed the care and then handed the resident her call light while still wearing the same gloves used during the incontinence care. In an interview at 11:56 A.M. the same day, CNA #97 confirmed that she did not perform hand hygiene after completing the incontinence care and had handed the call light to the resident while wearing soiled gloves. The facility identified 20 residents who required assistance with incontinence care, indicating the potential scope of this deficient practice. This deficiency was based solely on the observed failure of CNA #97 to remove gloves and perform hand hygiene after providing incontinence care and before touching the resident’s call light, as well as the facility’s identification of multiple residents requiring similar care.
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