Improper Hand Hygiene and Wipe Use During Incontinence Care
Penalty
Summary
The deficiency involves the facility’s failure to ensure proper infection prevention and control practices during incontinence care for one resident. The resident was an elderly female with severe cognitive impairment due to dementia, Alzheimer’s disease, stroke, and malnutrition, who was always urinary and bowel incontinent and dependent on staff for toileting hygiene and repositioning. Her care plan identified existing or potential pressure ulcers with a goal that ulcers show signs of healing and remain free from infection, and interventions included following facility policies for prevention and treatment of skin breakdown. Skin assessments documented intact skin initially, followed by multiple new pressure ulcers on the feet, toes, heels, and sacral area over time, and the resident was assessed as having a moderate/high risk for skin breakdown due to incontinence of urine and stool. During an observation of incontinence care, a CNA washed his hands and donned gloves, then removed the resident’s brief and cleaned the perineal area. While doing so, he used the same soiled wipe multiple times on the perineal area instead of discarding it after a single use, and he used his soiled, gloved hand to pull up his own sleeve before continuing incontinence care without changing gloves or performing hand hygiene. In a subsequent interview, the CNA stated he was unaware he had reused the same wipe and had adjusted his sleeve with a soiled glove, and he acknowledged this was not the facility’s standard practice. The DON stated staff were supposed to use one wipe and discard it before obtaining a new one, and that staff should perform hand hygiene after touching any part of their clothing. The facility’s infection control policy identified hand hygiene as the primary means of preventing transmission of infection and required hand hygiene after handling soiled or used linens and dressings.
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