Failure to Maintain Infection Control During Incontinence and G-Tube Care
Penalty
Summary
Staff failed to maintain proper infection control practices during incontinence and feeding tube care for two residents. During incontinence care for one resident, certified nurse aides did not sanitize their hands between glove changes, touched clean linens and the resident's bare skin with soiled gloves, and placed soiled linens on clean bedding. Wash cloths were laid on the side of the bathroom sink, potentially contaminating them, and were then used to wipe the resident. The resident was rolled onto a urine-soaked sheet, and the mattress was not properly cleaned or allowed to dry before clean linens were applied. Additionally, the resident's bleeding chin was not addressed, and blood was left on the resident's neck and bed sheet, which was not changed after care or following medication administration through a gastrostomy tube by a registered nurse. In a separate incident, a licensed practical nurse performed feeding tube care for another resident without proper hand hygiene. The nurse did not clean hands before or after entering the room, handled a soiled washcloth identified as having stool, removed gloves without washing hands, and then donned new gloves. The nurse continued with the feeding tube procedure, including checking tube placement, administering feeding and water flushes, and handling equipment, all without appropriate hand hygiene between tasks. The nurse only washed hands after removing gloves, gown, and mask at the end of the procedure. The infection preventionist confirmed that staff should sanitize hands and change gloves between dirty and clean tasks, avoid touching residents or clean linens with soiled gloves, and ensure soiled linens are not placed on clean bedding. The infection preventionist also stated that contaminated wash cloths should not be placed on the side of the sink, and that mattresses should be cleaned and dried if soiled. The facility's incontinence care skills validation form indicated that hand washing and glove use are required, but these practices were not consistently followed by staff during the observed incidents.