Failure to Follow Infection Control Protocols During Incontinent Care
Penalty
Summary
A deficiency was identified when a certified nursing assistant (CNA) failed to follow proper infection prevention and control procedures during incontinent care for a female resident with diabetes mellitus, unsteadiness, muscle weakness, and incontinence. The CNA reused disposable wipes for multiple strokes during perineal care, rather than using a new wipe for each stroke as required by facility policy. Additionally, the CNA did not sanitize her hands between glove changes throughout the procedure, despite being aware of the correct protocol and having recently received in-service training on hand hygiene and perineal care. The resident involved required substantial to maximal assistance with activities of daily living, including toileting hygiene, and was always incontinent of bladder and bowel. During the observed care, the CNA performed initial hand washing and donned gloves, but then used the same side of wipes for multiple cleaning strokes in the perineal and rectal areas, folding the wipes rather than discarding them after each use. The CNA also changed gloves during the procedure but did not sanitize her hands between glove changes, citing a lack of hand sanitizer in her pocket as the reason for this omission. Interviews with the CNA, other staff, and facility leadership confirmed that the expectation and policy were to use one wipe per swipe and to sanitize hands between glove changes. The facility's policies and training materials clearly outlined these requirements, and staff acknowledged understanding of the procedures. Despite this, the observed practice did not align with established protocols, resulting in a failure to implement the infection prevention and control program as designed.