Failure to Follow Infection Control Practices During Perineal Care
Penalty
Summary
Surveyors observed that staff failed to follow established infection control practices during perineal care for two residents with severe cognitive impairment. Certified Nursing Assistants (CNAs) were seen removing gloves from their pockets and applying them without performing hand hygiene, and handing gloves to each other without washing hands. During care, CNAs continued to use soiled gloves while moving from dirty to clean areas, applied clean briefs with contaminated gloves, and retrieved perineal wipes from the package with soiled gloves. These actions were acknowledged by the CNAs during interviews, who admitted to not following proper procedures and recognized the potential for infection. Additionally, one CNA was observed touching the bed remote control with gloved hands before starting care and then proceeding to clean feces from a resident, again using soiled gloves to retrieve additional wipes. The LPN/Infection Preventionist and the Director of Nursing confirmed that these practices were not in accordance with facility policy, which requires hand hygiene before care and prohibits storing gloves in pockets. Both staff members acknowledged that the observed practices placed residents at risk for infection and skin breakdown.