Failure to Follow Hand Hygiene and Equipment Sanitization During Perineal Care
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program related to incontinence and perineal care for two residents. Resident #1 was an older male with dementia, severe cognitive impairment (BIMS score of 6), bilateral lower extremity weakness, and a need for partial to moderate assistance with all ADLs. During observation of perineal care for this resident, LVN A cleaned the resident’s soiled perineal area and then applied cream to the perineal area without changing gloves between the dirty and clean tasks. LVN A also moved a bedside table from Resident #1’s room to another resident’s room without sanitizing the table or changing the covering linen. Resident #2 was an older male with Alzheimer’s disease, severe cognitive impairment (BIMS score of 5), bilateral lower extremity weakness, and dependence to substantial/maximal assistance for all ADLs. During observation of perineal care for this resident, LVN A applied cream to the perineal area, removed gloves, donned clean gloves without performing hand hygiene, applied cream to the groin area, then again removed gloves and donned clean gloves without sanitizing hands between glove changes. Interviews with LVN A, CNA A, the DON, and the Administrator confirmed that facility policy and staff training required changing gloves when moving from dirty to clean tasks, performing hand hygiene after glove removal and before donning clean gloves, and sanitizing shared equipment such as bedside tables between resident rooms, which did not occur during the observed care.
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