Failure to Prevent Cross-Contamination During Incontinence Care
Penalty
Summary
Certified Nursing Assistants (CNAs) failed to follow proper infection control procedures during incontinence care for two residents. In one instance, a CNA provided incontinence care to a resident with severe cognitive impairment and multiple diagnoses, including Alzheimer's Disease and diarrhea, without changing gloves between dirty and clean tasks. The CNA used the same contaminated gloves to cleanse the resident, handle clean briefs, remove personal items, and apply barrier cream, contrary to facility policy and infection control standards. The resident was dependent on staff for all personal hygiene and was always incontinent of bowel and bladder. In another case, a CNA and a hospice nurse transferred a resident with severe cognitive impairment, diabetes, a history of C. diff, and other conditions. The CNA threw a soiled incontinence brief onto the resident's bed linens and provided care, including applying barrier cream, before changing gloves. The soiled brief remained on the bed linens until after care was completed, creating a risk of cross-contamination. Both incidents were observed and confirmed through interviews and record reviews, and were not in accordance with the facility's policies on incontinence care and glove use.