Failure to Follow Infection Control Protocols During Perineal Care
Penalty
Summary
A deficiency was identified when a nurse failed to follow established infection prevention and control protocols during the provision of perineal care to a resident with severe cognitive impairment. The resident, who had diagnoses including unspecified dementia, hypertension, and depression, was observed standing in her room with wet socks and pants on the floor. The nurse entered the room wearing PPE, although the resident was not on any type of precautions, and did not assist the resident to the bed or provide privacy. During care, the nurse used a single washcloth to wipe both the resident's buttocks and between her legs, contrary to facility policy requiring separate washcloths for each area. The soiled washcloth and towel were thrown onto the floor instead of being placed in a designated receptacle. The nurse then retrieved clean clothing from the closet without removing her gloves, dressed the resident, and only after handling soiled linens and removing PPE did she doff her gloves, not following the correct order for PPE removal or hand hygiene procedures. Interviews with the nurse, DON, and Administrator confirmed that the actions taken did not align with facility policies for infection control, perineal care, handling of soiled linens, and PPE use. The nurse admitted to not following proper procedures, including the handling of soiled items and PPE removal, and facility leadership stated expectations that staff adhere to established infection control guidelines.