Failure to Follow Infection Control Protocols During Incontinent Care
Penalty
Summary
Staff failed to follow proper infection prevention and control procedures during incontinent care for a resident who was dependent for mobility, always incontinent of bowel and bladder, and had a stage 2 sacral pressure injury. The resident was on Enhanced Barrier Precautions (EBP), as indicated by physician orders and signage on the door. During observed care, two CNAs entered the room without donning the required personal protective equipment (PPE), specifically gowns, and proceeded to provide perineal care while wearing only gloves. Both CNAs used cleaning wipes multiple times, tucked used wipes into the soiled brief, and touched various surfaces and their own clothing with contaminated gloves. Neither CNA performed hand hygiene or used hand sanitizer at any point during the care, despite changing gloves several times. The Director of Nursing (DON) entered the room during the care episode and instructed the CNAs to don gowns, as required for EBP and due to the resident's wound. The DON then participated in care, but was observed to handle the resident's arm brace and reposition the resident while wearing the same gloves used to handle soiled materials, without changing gloves or performing hand hygiene. After care was completed, it was confirmed that the only hand sanitizer in the room was located by the door, and both CNAs acknowledged they had not used it during the procedure. Interviews with the CNAs and a restorative CNA revealed knowledge of the need for glove changes and hand hygiene, but this was not practiced during the observed care. Further review revealed that the facility did not have written policies for Enhanced Barrier Precautions, incontinent care, or hand washing. The administrator confirmed the absence of these policies when requested by the surveyor. The lack of adherence to infection control protocols and the absence of guiding policies contributed to the deficiency identified during the survey.