Failure to Change Gloves and Perform Hand Hygiene During Incontinent Care
Penalty
Summary
The deficiency involves a failure to follow infection prevention and control practices during incontinent care for one resident. The resident was an elderly female with multiple serious medical conditions, including pneumonia, MRSA infection, a stage 4 sacral pressure ulcer, type 2 diabetes mellitus, a tracheostomy, a gastrostomy, and neuromuscular bladder dysfunction. Her MDS assessment showed she was severely cognitively impaired, rarely understood and could rarely be understood, and was dependent on staff for ADLs. Her care plan identified bowel incontinence with an intervention to provide perineal care after each incontinent episode. During observation of incontinent care, an LVN wiped feces from the resident’s anal area, discarded the soiled wipe, and then continued handling the soiled brief and placing a clean brief under the resident without removing her soiled gloves, performing hand hygiene, and donning clean gloves. She completed the incontinent care while still wearing the same contaminated gloves. In a subsequent interview, the LVN acknowledged she should have removed the soiled gloves, sanitized her hands, and put on clean gloves before placing the clean brief. The ADON stated the nurse should have changed gloves after cleaning the anal area to prevent cross-contamination. Facility policies on perineal care and hand hygiene required doffing gloves and performing hand hygiene after contact with body fluids or excretions, which were not followed in this instance.
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