Failure to Follow Infection Control Protocols During Incontinent Care
Penalty
Summary
Certified Nursing Assistants (CNAs) failed to follow proper infection prevention and control protocols while providing incontinent care to a resident with multiple medical conditions, including schizophrenia, PTSD, type 2 diabetes, gastrostomy status, hypertension, and Parkinson's disease. The resident required total assistance with activities of daily living and was always incontinent of bowel and bladder. During care, one CNA touched the bed remote and another touched the privacy curtain with gloved hands, both of which are considered contaminated surfaces. Neither CNA changed gloves or performed hand hygiene before proceeding with direct care for the resident, who was on enhanced barrier precautions due to gastrostomy status. Interviews with the CNAs revealed they were aware that the bed remote and privacy curtain were considered dirty and acknowledged they should have changed gloves and sanitized their hands, but did not realize this was required before starting care. Both CNAs had received infection control training and passed competency checks on hand hygiene. The Director of Nursing confirmed that staff are expected to change gloves and sanitize hands prior to providing care to prevent cross-contamination and infection, and that infection control training and skills checks are conducted at least annually. Facility policy also requires hand hygiene before and after direct resident contact and when moving from contaminated to clean procedures.