Failure to Follow Infection Control Practices During Resident Care
Penalty
Summary
The facility failed to implement proper infection control practices during care for two of three residents observed. In one instance, during incontinence care, a CNA sanitized hands and donned gloves, while an RN only donned gloves. The CNA then gathered supplies with gloved hands, provided care, and applied barrier cream without changing gloves or performing hand hygiene between tasks. The same gloves were used to place barrier cream and to put on a clean incontinence brief, with the CNA wiping the gloved hands inside the clean brief. The RN removed soiled gloves and washed hands after care, but the CNA did not change gloves or perform hand hygiene as required by facility policy. In another instance, during wound care, an RN applied hand sanitizer, donned a gown and gloves, and performed wound care procedures. After removing the gown and gloves, the RN put on a new pair of gloves to apply a heel boot but did not perform hand hygiene during or after the procedure. The facility's policy requires gloves to be changed and hand hygiene to be performed when moving from dirty to clean tasks and after glove removal, which was not followed in these observed cases.