Failure to Follow Infection Control Practices During Perineal Care
Penalty
Summary
Staff failed to adhere to infection control practices during perineal care for three out of 34 sampled residents. Certified Nurse Aides (CNAs) were observed not changing gloves or performing hand hygiene after contact with soiled materials and before touching clean items or other surfaces. In one instance, a CNA performed peri care on a resident who was having a bowel movement, used the same gloves to touch the resident’s bedside table, nightstand, nasal cannula, and to dispose of trash, and then exited the room and walked down the hallway still wearing the soiled gloves. In other cases, CNAs were observed pulling up residents’ clothing, adjusting blankets, moving walkers, and handling dirty linens and doorknobs while still wearing soiled gloves, and in some instances, only partially removing gloves before performing hand hygiene. The facility’s own Nursing Assistant Clinical Skills Checklist and Perineal Care procedures require staff to remove and discard gloves and perform hand hygiene after contact with soiled materials. Interviews with the involved CNAs confirmed awareness of the improper practices, and the Clinical Care Coordinator stated that staff are expected to follow established protocols, including hand hygiene and not touching items around the room or leaving the room with soiled gloves.