Failure to Follow Hand Hygiene and Perineal Care Protocols
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program when staff did not perform required hand hygiene between resident contacts during meal tray distribution and while providing perineal care. During a hallway lunch tray pass, a CNA passed trays sequentially to multiple residents without performing hand hygiene between rooms, including entering a room with enhanced barrier precautions signage and then continuing to other residents without sanitizing or washing hands. In an interview, the CNA acknowledged forgetting to use hand hygiene between each resident and stated that residents could get an infection if staff did not conduct hand hygiene between residents. In a separate observation of perineal care for a resident who was incontinent of bowel and bladder, another CNA pulled adult wipes from the package with soiled gloves while cleansing the peri-area and did not change gloves when moving from the peri-area to the bottom. The CNA continued to pull wipes one at a time from the package with contaminated gloves. In a subsequent interview, this CNA stated she had been trained to change gloves and perform hand hygiene before and after peri-care and acknowledged that she should perform hand hygiene and glove changes three times during the process and that not doing so could lead to infection in residents. Record review for the resident receiving peri-care showed she was an older female with multiple diagnoses, including COPD, heart failure, osteoporosis, pain, urinary tract infection, hypertension, lack of coordination, and an old myocardial infarction. Her care plan documented bowel and bladder incontinence, a goal to prevent skin breakdown related to incontinence, and a need for extensive assistance with personal hygiene, including incontinent care. Facility policies for hand hygiene and perineal care required staff to perform hand hygiene between resident contacts, when moving from contaminated to clean body sites, and to change gloves and perform hand hygiene when gloves became soiled, which was not followed in the observed instances. The administrator and DON both described infection control expectations consistent with these policies, including hand hygiene and glove changes before and after resident care and when handling soiled materials, and stated that failure to follow these precautions could spread infection from one resident to another.
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