Failure to Follow Infection Control Protocols During Incontinent Care
Penalty
Summary
A deficiency was identified when a CNA failed to follow proper infection prevention and control protocols while providing incontinent care to a resident. The CNA entered the resident's room without performing hand hygiene, placed gloves on a roommate's bed, adjusted the bed rail, and then put on the gloves without hand hygiene. Throughout the care process, the CNA repeatedly failed to change gloves and perform hand hygiene at appropriate times, including after removing soiled items, before handling clean items, and after glove removal. The CNA also used gloves that had been placed on another resident's bed and touched personal items such as her own glasses during care without changing gloves or performing hand hygiene. Interviews with the CNA and the DON confirmed that the facility's infection control policy required hand hygiene before and after resident care, between glove changes, and when moving from clean to dirty tasks. The facility's policy also emphasized that gloves do not replace the need for hand hygiene and that failure to change gloves between resident contacts is an infection control hazard. The observed actions were inconsistent with these policies and could contribute to the transmission of communicable diseases and infections within the facility.