F0880

D

Failure to Perform Hand Hygiene During Incontinence Care

Sherman, Texas Survey Completed on 03-26-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure proper hand hygiene practices during incontinence care for one resident. The resident was an older male with seizure disorder/epilepsy, hypertension, and depression, with a BIMS score of 07 indicating severely impaired cognition, and required substantial/maximal one-person physical assistance with toilet use and personal hygiene. During an observed episode of incontinence care, the CNA entered the bathroom in response to the call light, found the resident standing next to the toilet with pants and brief down, washed her hands, and donned clean gloves. She then cleaned the resident’s buttocks and the tip of his penis using wipes and removed a urine-soaked brief.

After completing the cleaning of the resident’s perineal area, the CNA obtained and applied a clean brief without changing gloves or performing hand hygiene. She then assisted the resident in pulling up his pants, returning to the wheelchair, washing his hands, and exiting the bathroom. The CNA removed her gloves, exited the bathroom, immediately donned new gloves from a box near the exit door without performing hand hygiene, and proceeded to make the resident’s bed and handle dirty linens and trash before finally removing gloves and sanitizing her hands upon leaving the room. In interviews, the CNA acknowledged she was supposed to wash hands before and after care, and to change gloves and perform hand hygiene before applying a clean brief, stating she did not do so because she was nervous. The ADON confirmed that facility expectations and policy required hand hygiene and glove changes when moving from dirty to clean tasks, and record review of the hand hygiene policy specified hand hygiene before and after resident contact, before moving from a soiled to a clean body site on the same resident, and immediately after glove removal.