F0880

D

Failure to Follow Hand Hygiene and Glove Protocol During Perineal Care

Yukon, Oklahoma Survey Completed on 03-05-2026

Penalty

No penalty information released

Summary

The deficiency involves a failure to follow infection prevention and control practices, specifically hand hygiene and glove use, during perineal care for one resident. During an observation of incontinent care, a CNA performed perineal care on a resident who was dependent for toileting and bed mobility and frequently incontinent of bowel and bladder. After the resident had a bowel movement, the CNA wiped stool from the resident and was observed wiping stool from their gloved hand onto the pad under the resident. Without changing gloves, the CNA then placed a clean brief under the resident, touched the wipes package, placed it on the resident's table, turned the resident, and continued to touch the resident, the wipes package, and a cleaning solution with the same contaminated gloves.

The CNA continued the care by fastening the clean brief, removing the soiled pad and placing it at the foot of the bed, and putting clean pants on the resident, all without changing gloves. The CNA then touched the resident's covers and draw sheet with the same gloved hands. At the end of care, the CNA removed their gloves, took the trash, and left the room without performing hand hygiene after glove removal or before handling the trash. There was no observation that hand hygiene was performed at any point. The facility's perineal care policy required staff to remove feces, dispose of gloves and used supplies, perform hand hygiene, and then apply new gloves before placing a new brief and changing linens. The resident involved had active diagnoses of urinary tract infection and septicemia. In a subsequent interview, the CNA stated that gloves were supposed to be changed after cleaning stool and after completing incontinent care and acknowledged they did not think they changed their gloves because they were nervous.