Failure to Follow Infection Control Practices During Resident Care
Penalty
Summary
A deficiency occurred when a certified nursing assistant (CNA) failed to follow proper infection prevention and control practices while providing incontinence care to a male resident with epilepsy and moderate cognitive impairment. The resident's care plan required cleaning the peri-area with each incontinence episode. Video evidence showed the CNA eating food from a bag with her hands, touching various surfaces in the resident's room, and then proceeding to provide direct care to the resident without performing hand hygiene or using hand sanitizer at any point during the interaction. The CNA was observed picking up items from the floor, handling the resident's bedding, and touching the resident and his diaper with the same hands used to eat food. She donned gloves only after handling multiple potentially contaminated items and did not use wipes during incontinence care, instead using the dirty diaper to wipe the resident. The CNA also placed a clean diaper that had fallen on the floor onto the resident and continued to handle the resident's blankets and trash while wearing the same gloves used for incontinence care. At no time was hand hygiene performed before, during, or after the care episode. Facility policies required staff to wash and dry hands thoroughly before and after providing care, use gloves appropriately, and perform hand hygiene after glove removal and after contact with potentially contaminated surfaces. The CNA had completed required infection control training, but her actions during this incident did not align with facility policies or standard precautions, as confirmed by interviews with facility leadership and review of training records.