Failure to Follow Infection Control Procedures During Incontinence Care
Penalty
Summary
A deficiency was identified when a Certified Nurse Assistant (CNA) failed to follow proper infection control procedures during incontinence care for a resident who was under enhanced barrier precautions (EBP). The CNA donned a gown and gloves to provide care and used wipes to remove feces from the resident, who was always incontinent of bowel and bladder and had multiple medical diagnoses, including respiratory failure and diabetes. The CNA did not remove her gloves or perform hand hygiene before placing a clean incontinence brief on the resident and covering them with a sheet. Upon interview, the CNA confirmed she did not change gloves after cleaning feces and was unaware that glove changes were required when wearing PPE for EBP. Review of the facility's hand hygiene policy and CDC recommendations confirmed that hand hygiene should be performed before moving from a soiled to a clean body site and that glove use does not replace the need for hand cleaning. This lapse in infection control was observed and verified during the survey.