Failure to Maintain Infection Control During Incontinence Care
Penalty
Summary
During incontinence care for a resident with Alzheimer's Disease, quadriplegia, tracheostomy status, and dysphagia, two CNAs gathered supplies, provided privacy, washed their hands, and donned gloves. One CNA removed a soiled brief and provided peri care, but then, without changing her gloves or performing hand hygiene, touched the barrier cream container, applied the cream to her gloves, and then to the resident's peri area. She continued care to the resident's buttocks and applied a new brief, all while wearing the same soiled gloves. The CNA only removed her gloves and washed her hands after completing all care tasks. Interviews with the CNA, a unit manager RN, and the DON confirmed that the CNA should have removed her soiled gloves and performed hand hygiene before touching the barrier cream container and before applying the cream to the resident. Facility policy on standard precautions also requires hand hygiene after contact with body fluids or excretions and after glove removal.