Failure to Follow Infection Control Protocols During Incontinence Care
Penalty
Summary
Certified Nursing Assistants (CNAs) A and B failed to follow proper infection prevention and control protocols during incontinence care for a resident who was dependent for toileting and had multiple diagnoses, including diabetes mellitus, heart failure, anemia, anxiety disorder, malnutrition, and chronic obstructive pulmonary disease (COPD). During the observed care, the resident had a bowel movement and was wet. CNA A cleaned the resident's front, including the penis, while CNA B cleaned the buttocks. Both CNAs did not change gloves or perform hand hygiene between tasks, and subsequently put a clean brief on the resident and handled the resident's personal belongings without changing gloves or sanitizing their hands. Interviews with both CNAs revealed that they were aware of the requirement to change gloves and perform hand hygiene but chose not to do so, citing reasons such as working quickly and feeling nervous under observation. The facility's Infection Preventionist and Director of Nursing (DON) confirmed that staff are expected to change gloves and perform hand hygiene after cleaning a resident, as per facility policy. The facility's hand hygiene policy, last updated in January 2025, emphasizes the importance of hand hygiene in preventing the spread of healthcare-associated infections and requires all personnel to adhere to these practices.