Failure to Follow Hand Hygiene and Glove Use Practices During Incontinent Care
Penalty
Summary
The deficiency involves the facility’s failure to maintain an effective infection prevention and control program during incontinent care for one resident. The resident was an elderly female with multiple diagnoses, including unspecified cerebral infarction, contracture of the left hand, neuromuscular bladder dysfunction with incontinence, unspecified dementia with psychotic disturbance, and constipation. A quarterly MDS showed a BIMS score of 06, indicating severe cognitive impairment, and documented that she was dependent on staff for toileting hygiene and was frequently incontinent of bowel and bladder. Her care plan identified potential or actual skin integrity impairment related to fragile skin, incontinence, limited mobility, and hemiplegia, with an intervention to keep skin clean and dry, but did not include a specific focus or problem for incontinent care. During an observation of incontinent care, two CNAs provided care to the resident. CNA A initially washed her hands, then used bare hands to manipulate the bed control and bed frame to position the resident for care. Without washing her hands after touching these room surfaces, CNA A donned clean gloves and handled clean wet wipes, arranging them on a clean surface. After completing perineal care with those gloves, CNA A used the same soiled gloves to grab and prepare a clean brief and clean bed pad. Only after preparing these clean items did CNA A remove the soiled gloves and wash her hands, then don clean gloves to place the prepared brief and bed pad under the resident, and incontinent care was completed. In interviews, CNA A acknowledged that she should have washed her hands after touching the bed control and bed frame and before donning gloves, and that she should have removed gloves, washed hands, and applied new gloves before touching the clean brief and bed pad. She stated that facility policy required handwashing after every glove change and after touching room items, and that failure to follow this could lead to infections such as UTIs. The DON and the Assistant DON/Infection Preventionist both confirmed that staff were expected to wash hands before donning gloves, between glove changes, and after touching items in the resident’s environment, consistent with facility policy. Record review showed CNA A had prior competency evaluations in handwashing, PPE use, and pericare, and had completed an infection control training course. The facility’s hand hygiene policy required hand hygiene before and after resident contact, after contact with objects in the resident’s vicinity, and after removing gloves, which was not followed during this observed episode of care.
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