F0880

D

Failure to Follow Hand Hygiene and Glove-Change Protocol During Incontinence Care

Graham, Texas Survey Completed on 03-25-2026

Penalty

No penalty information released

Summary

Surveyors identified a deficiency in the facility’s infection prevention and control program related to incontinence care provided to Resident #1. Resident #1 was an 87-year-old female with neuromuscular dysfunction of the bladder, cellulitis of the right lower limb, a cutaneous abscess of the right upper limb, gangrene, and diabetes mellitus. Her MDS assessment showed she required substantial/maximal assistance with most ADLs, including toileting, and she was occasionally incontinent of bladder and frequently incontinent of bowel. Her care plan documented bowel incontinence with a goal of avoiding complications related to that condition.

During observed incontinence care, CNA A did not wash her hands prior to donning gloves and removed a feces-soiled brief from the resident. CNA A wiped the resident from front to back but did not change gloves, continuing to clean the resident with gloves that were visibly soiled with fecal matter. Without changing gloves or performing hand hygiene, CNA A retrieved and placed a clean brief under the resident and applied skin protector while still wearing the soiled gloves, then removed the gloves, picked up trash, and exited the room without performing hand hygiene. In an interview, CNA A acknowledged she should have changed gloves and washed hands before retrieving and placing the clean brief, stated she had not received complete infection control training with return demonstration, and described cross contamination as mixing clean with dirty, which she recognized had occurred during the care. The facility’s infection control policy for female perineal care required staff to wash hands and don clean gloves for perineal care and to change gloves if they became contaminated with feces.