Inadequate glove use, linen handling, and EBP adherence during incontinent care
Penalty
Summary
Surveyors identified deficiencies in the facility’s infection prevention and control program related to incontinent care and enhanced barrier precautions. For one resident with dementia and senile degeneration of the brain who was incontinent of bowel and bladder, a CNA donned gloves and began incontinent care, placing a clean brief on the bedside table, removing a soiled brief with fecal matter, and cleaning the resident. The CNA then placed a new brief and pad under the resident, removed the old pad and dropped it on the floor, and continued to adjust the resident’s brief, bed, sheet, call light, and bedside table without changing gloves. The CNA later picked up the pad and trash bag from the floor and disposed of them before removing gloves and performing hand hygiene. The facility’s policy required soiled linen to be collected at the bedside and placed in a linen bag, and the CNA acknowledged they should not have placed the pad on the floor and should have changed gloves twice during incontinent care. For another resident who was occasionally incontinent and required staff assistance with perineal care, a CNA donned gloves, prepared clean supplies, and unfastened a urine-soiled brief. The CNA tucked the soiled brief between the resident’s legs, wiped the resident, and placed dirty wipes on the foot of the bed on top of the sheet. The CNA rolled the resident, tucked the soiled brief under them, applied a clean brief, and then removed the soiled brief and placed it at the foot of the bed on top of the sheet. While still wearing the same soiled gloves, the CNA handed the resident a stuffed animal, adjusted clean sheets, moved the bedside table, used the bed remote, and handed the call light to the resident. The CNA also reached into their jacket pocket with contaminated gloves to handle clean gloves and a trash bag roll before finally doffing gloves and exiting the room. The CNA later stated they should have changed gloves after touching the dirty brief and should not have placed soiled items on the bed or touched clean items and supplies with contaminated gloves. For a third resident on enhanced barrier precautions due to a pressure ulcer and other specified local skin infections, an EBP sign and PPE were present outside the room. A CNA used hand sanitizer, donned gloves, prepared a clean brief, and changed gloves before unfastening a brief and discovering feces. The CNA wiped the resident, tucked the soiled brief under them, and applied a clean pad and brief. After removing the soiled brief and disposing of it, the CNA pulled the clean brief into place and then doffed gloves. The CNA donned another pair of gloves from their jacket pocket, positioned a pillow, covered the resident with a blanket, lowered the bed, placed a fall mat, removed and replaced the trash bag, and then doffed gloves and washed their hands. The facility’s EBP policy required gown and glove use for high-contact care activities such as changing briefs, and the resident’s care plan specified PPE use throughout their stay or until wounds healed. The CNA later stated that EBP meant washing hands or using sanitizer, wearing gloves and a gown, and acknowledged they did not think about wearing a gown during incontinent care and should have changed gloves after removing the soiled brief. The DON stated the facility’s process required changing gloves between clean and dirty surfaces and wearing gloves and a gown for incontinent care for residents on EBP.
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