Based on observation, interview, and record review, the facility failed to maintain infection control practices to prevent the development and transmission of infection during incontinent care for one resident (Resident #3) out of 15 sampled residents and one resident (Resident #16) outside the sample. The facility's census was 59. Review of the facility's Handwashing policy, revised June 2024, showed: - The purpose is to ensure that hand washing is conducted appropriately; - Personnel should always decontaminate their hands before having direct contact with patients; after a situation during which unanticipated microbial contamination of hands might have occurred, especially those involving contact with mucous membranes, blood or other body fluids, secretions, or excretions; if moving from a contaminated body site to a clean body site during patient care; after touching inanimate sources that might have been contaminated with virulent or epidemiological microorganisms; and after removing gloves; - Wearing gloves does not replace the need for hand washing because gloves may have small unapparent defects, may be torn during use and hands can become contaminated during removal of gloves; - Facility-approved waterless hand sanitizer may be used in place of washing hands with soap and water as long as hands are not visibly soiled; - If an employee is non-compliant, they must wear gloves at all times when they are with patients and the hand hygiene policy must be reviewed with the employee and documented as a corrective action. Review of the facility's Perineal Care with a Catheter policy, revised January 2024, showed: - Wash hands and apply gloves; - Place bed protector under buttocks; - Expose the perineal area; - For the female resident, separate the labia and gently wash around the opening of the urethra with disposable non-rinse wipes; - Wash the catheter from the opening of the urethra outward four inches or farther if needed. Do not pull on catheter; - Using a fresh non-rinse wipe, continue washing the peri area. Dry the perineal area; - Remove any soiled items and place in appropriate container; - Remove gloves and dispose in appropriate container. Wash hands; - Apply clean gloves before applying barrier cream. Remove gloves, wash hands. 1. Observation of Resident #3 on 09/12/24 at 9:12 A.M. showed: - Certified Nursing Assistant (CNA) A and CNA C sprayed disposable wipes with peri-wash on a barrier on a supply cart outside the room, entered the resident's room, washed their hands, and donned gloves and a gown; - CNA C helped to position the resident while CNA A cleaned the resident's perineal area and catheter with two separate wipes and placed the used wipes on the disposable bed pad; - CNA A, while performing peri and catheter care, found bowel movement (BM) on his/her glove, removed gloves and laid the soiled gloves on the disposable bed pad with the soiled wipes; - CNA C positioned the resident on the resident's right side; - Without performing hand hygiene, CNA A donned new gloves and cleaned the resident's buttocks again with two separate wipes, placed the used wipes on the soiled bed pad and then wiped BM from the resident's buttocks with the corner of the disposable bed pad and folded the soiled corner of the bed pad over onto itself; - CNA C removed gloves, did not perform hand hygiene, went out in the hall to get more gloves, re-entered the room, washed hands, donned gloves and handed gloves to CNA A; - CNA A removed gloves and, without performing hand hygiene, donned new gloves and continued to wipe BM from the resident's buttocks with wipes; - CNA A rolled up the bed pad and tucked it under the resident; - While CNA B repositioned the resident, CNA A pulled the soiled disposable bed pad from under the resident and handed the soiled bed pad containing soiled wipes to CNA C, who threw the bundle in the trash can beside him/her; - CNA A and CNA C removed gloves and, without performing hand hygiene, donned new gloves; - CNA A then wiped the resident's catheter and peri area again and put a new disposable bed pad under the resident; - With the same soiled gloves, CNA A covered the resident with a blanket; - CNA A and CNA C removed their gloves and gowns; - CNA A washed his/her hands while CNA C pulled the full trash bag from the trash can with bare hands, tied the bag, and set it on the floor beside the trash can; - CNA C washed his/her hands, grabbed the top of the bag of trash with a paper towel, and both CNAs left the room. 2. Observation of Resident #16 on 09/12/24 at 9:51 A.M. showed: - CNA A and CNA B entered the room and washed their hands; - CNA A touched the resident's closet door, clothes in the closet, and the resident's bed, then donned gloves; - CNA B donned gloves; - CNA B positioned the resident while CNA A performed peri care; - CNA A reached for loose wipes on a barrier on the nightstand with gloves being used to perform peri care and touched the clean gloves sitting beside the wipes; - CNA A and CNA B removed the disposable bed pad from under the resident, and CNA B disposed of it in the trash can near CNA A; - CNA A removed her gloves and, without performing hand hygiene, donned the last pair of gloves that was sitting on the nightstand; - CNA B removed his/her gloves; - CNA A laid a clean brief under the resident and applied barrier cream while CNA B helped position the resident with bare hands; - Without performing hand hygiene, CNA A and CNA B fastened the clean brief's tabs on either side of the resident and dressed the resident with bare hands; - Without performing hand hygiene, CNA B opened the door, went into the hall to retrieve the sit to stand and the resident's wheelchair; - Without performing hand hygiene, CNA A touched the resident, his/her clothing, bed, and pillow with bare hands; - Without performing hand hygiene and with bare hands, CNA A and CNA B reached under the resident's arms to position the resident on the edge of the bed and fastened the sit-to-stand sling on the resident for a bed to wheelchair transfer; - Once the resident was transferred to the wheelchair, and without performing hand hygiene, CNA B brushed the resident's hair, touching the hairbrush and the resident's hair with his/her bare hands; - CNA A and CNA B washed their hands and exited the room with the resident. During an interview on 09/12/24 at 2:21 P.M., the Infection Preventionist (IP) said she would strongly encourage staff to wash/sanitize their hands with glove changes. Staff should wash before starting peri care and perform hand hygiene and put on new gloves before cleaning up a bowel movement. If the resident has a catheter and catheter care needs done again after cleaning up the bowel movement, staff should perform hand hygiene and put on new gloves before performing catheter care again. During an interview on 09/12/24 at 2:30 P.M., CNA B said he/she normally washes before beginning resident care and after resident care. In between tasks during resident care such as peri-care, he/she usually just changes gloves and does not wash or sanitize hands. It just depends on what he/she is doing whether or not he/she washes or sanitizes hands during patient care. During an interview on 09/13/24 at 9:23 A.M., CNA A said he/she washes before and after resident care and sanitizes throughout the day. He/She should sanitize when moving from dirty to clean or before dressing a resident after pericare. During an interview on 09/13/24 at 11:00 A.M., the Director of Nursing (DON) said she would expect staff to perform hand hygiene with glove changes. They don't necessarily have to wash their hands; sanitizer is fine. She would expect staff to perform hand hygiene prior to starting resident care, when going from dirty to clean, and after resident care. Staff should also perform hand hygiene after peri care and prior to personal care, such as dressing or transferring the resident.