Failure to Maintain Infection Control During Incontinence Care
Penalty
Summary
During an observation of incontinence care for Resident #32, a CNA failed to maintain proper infection control practices. The CNA did not perform hand hygiene before entering the resident's room, after changing gloves, or before exiting the room. Instead, the CNA repeatedly donned new gloves without washing or sanitizing hands between glove changes. Additionally, the CNA placed washcloths directly in the resident's bathroom sink, rather than using a clean basin as required by facility policy. These actions were witnessed during the care of a resident who was always incontinent of bladder and bowel and had a history of urinary tract infections, chronic kidney disease, and impaired mobility. Interviews with the CNA, another CNA, an RN, and the Director of Nursing confirmed that the correct procedure was not followed. All staff interviewed acknowledged that hand hygiene should be performed before and after glove use and before entering and after exiting the resident's room. Facility policy also requires the use of a clean basin for incontinence care and prohibits placing washcloths in the sink due to infection control concerns. The failure to adhere to these protocols was confirmed by both staff interviews and review of facility policies.