Failure to Follow Infection Control Procedures During Incontinence Care
Penalty
Summary
A certified nursing assistant (CNA) failed to follow proper infection prevention and control procedures during incontinence care for a resident. The CNA did not change gloves or perform hand hygiene after cleaning the resident's perineal area and before applying a clean brief. This action was observed while the resident, who was in bed, awake, alert, and confused, received care. The CNA acknowledged awareness of the required procedures but chose not to follow them due to concerns about the resident playing with water in the sink. The resident involved had a history of stroke, non-Alzheimer's dementia, and was occasionally incontinent of bowel and bladder. The resident was severely cognitively impaired and had a self-care performance deficit related to dementia and decreased mobility. Both the Infection Preventionist and the Director of Nursing confirmed that staff are required to change gloves and perform hand hygiene after cleaning a resident, as outlined in the facility's handwashing policy. The failure to adhere to these procedures was identified through observation, interviews, and record review.