Failure to Follow Hand Hygiene and Glove Use Practices During Incontinent Care
Penalty
Summary
The deficiency involves the facility’s failure to maintain its infection prevention and control program during incontinent care for one resident. The resident was an older male with acute kidney failure, COPD with exacerbation, muscle weakness, severe cognitive impairment (BIMS score 07), and was frequently incontinent of bowel and bladder. During an observation of incontinent care, a CNA entered the resident’s room, washed her hands, donned clean gloves, and assisted the resident from his wheelchair to the bed. She unfastened a urine-soaked brief that also contained a small bowel movement, cleaned the resident’s front area, and then helped him turn to his right side to clean his buttocks. After removing the soiled brief and placing it in a plastic bag, the CNA removed her gloves and then took a clean pair of gloves from her uniform pants pocket. The CNA put on the clean gloves without performing any hand hygiene between glove changes and then applied a clean brief and covered the resident. She removed her gloves, performed hand hygiene, and exited the room. In a subsequent interview, the CNA acknowledged she was required to perform hand hygiene before and after removing the dirty brief, to change gloves with hand hygiene after cleaning the resident and before applying a clean brief, and that she should not carry gloves in her pockets but obtain them from glove boxes in the room. She stated she forgot to bring hand sanitizer and recognized that not following hand hygiene and infection control policy could lead to cross contamination and infection. An RN interview confirmed that staff were expected to perform hand hygiene before and after care, to use hand sanitizer or wash hands when soiled, to change gloves and perform hand hygiene between dirty and clean tasks during incontinent care, and that gloves were supplied in each room and not to be carried in pockets. Review of the facility’s hand hygiene policy showed that hand hygiene is considered the primary means to prevent spread of infection, must be performed before and after applying non-sterile gloves, and that gloves do not replace hand hygiene.
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