Failure to Follow Infection Control Protocols During Incontinence Care
Penalty
Summary
The facility failed to maintain proper infection prevention and control practices during incontinence care for two residents. In the first instance, a cognitively intact female resident with a history of falls and incontinence required partial assistance with toileting. During observed care, a CNA washed her hands and donned gloves, but after cleaning the resident, she used soiled gloves to retrieve clean wipes from the container and did not perform hand hygiene after removing the soiled gloves. The CNA acknowledged she was aware of the correct procedure but did not follow it due to stress, recognizing the risk of infection to the resident. In the second instance, a cognitively impaired female resident with cancer and total incontinence also required partial assistance. During care, two CNAs washed their hands and donned gloves, but one CNA used soiled gloves to handle the wipes container and did not immediately change a soiled sheet after incontinence care, stating she would do so later because she was in a hurry. Both CNAs and facility leadership confirmed that these actions were not in accordance with facility policy, which requires glove changes and hand hygiene when moving from dirty to clean areas and prohibits touching clean supplies with soiled gloves.