Failure to Follow Infection Control Protocols During Incontinent Care
Penalty
Summary
The facility failed to maintain proper infection prevention and control practices during incontinent care for one resident. During an observed episode of care, a CNA did not follow established protocols for glove changes, hand hygiene, and the use of clean wipes. Specifically, the CNA used a single wipe to clean multiple areas, including the resident's buttocks, anal area, groin, and penis, without changing gloves or performing hand hygiene between tasks. The care was also performed in the incorrect order, starting from the back rather than the front. The resident involved was a male with significant medical conditions, including hemiplegia, diabetes mellitus, nontraumatic intracerebral hemorrhage, epilepsy, and cerebrovascular disease. He was nonverbal, dependent on staff for all activities of daily living, and always incontinent of bowel and bladder. His care plan required cleaning the perineum with each incontinent episode to prevent skin breakdown, and he had an order for zinc oxide ointment to be applied to the scrotum twice daily. Interviews with the CNA, another staff member, and the DON confirmed that the correct procedures were not followed. The CNA acknowledged not changing wipes, gloves, or performing hand hygiene, attributing the lapse to nervousness and not thinking clearly. The DON and another CNA both recognized the risk of infection due to these lapses and confirmed that the facility's policies required discarding wipes after each use, changing gloves, and performing hand hygiene between tasks.