Failure to Follow Infection Control Protocols During Incontinent Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program during incontinent care for a resident with Alzheimer’s disease and aphasia, who was at risk for skin breakdown and infection due to frequent bladder and bowel incontinence. During an observed episode of incontinent care, a CNA did not change her gloves after they became contaminated and did not clean the resident’s penis area as required by the care plan and facility policy. The CNA continued to use the same gloves while performing multiple tasks, including cleaning the resident’s buttocks, applying barrier cream, fastening a new brief, adjusting the resident’s clothing, and handling equipment for a transfer. Interviews with the DON and Administrator confirmed that the expected practice was for CNAs to change gloves once contaminated and to perform complete peri-care, including cleaning the penis area. Facility policies reviewed indicated the need for thorough perineal care and proper hand hygiene, including glove changes and hand sanitization after contact with potentially contaminated surfaces. The observed failure to follow these procedures was not in accordance with the facility’s infection control protocols.