Failure to Follow Infection Control Protocols During Incontinent Care for Resident on Contact Isolation
Penalty
Summary
A deficiency occurred when a certified nursing assistant (CNA) failed to follow infection prevention and control protocols while providing incontinent care to a resident on contact isolation for Clostridium difficile (C. diff). The CNA entered the resident's room without donning a gown, wore his face mask improperly under his chin, and did not perform hand hygiene before putting on gloves. During the care, the CNA did not change gloves or sanitize hands when moving between dirty and clean tasks, such as wiping, assisting with turning, removing clothing, and changing linens. The CNA also used the same gloves to remove clean wipes from their container, further breaching infection control practices. The resident involved was an elderly female with multiple complex medical conditions, including cerebrovascular disease, gastrostomy status, dysphagia, right-sided paralysis, esophageal stricture, malnutrition, rheumatoid arthritis, seizures, and a history of traumatic brain injury. She was totally dependent on staff for all activities of daily living, including toileting, dressing, and hygiene, and was always incontinent of bladder and bowel. At the time of the incident, she was on antibiotic therapy and under contact isolation for a confirmed C. diff infection, with appropriate signage and PPE supplies available outside her room. Despite documented policies, procedures, and regular in-service training on infection control, hand hygiene, and PPE use, the CNA had a history of non-compliance with these protocols, including previous counseling for similar issues. Staff interviews confirmed that infection control training was provided and that PPE and hand hygiene expectations were well known. The incident was observed via in-room surveillance video and corroborated by staff interviews and record reviews, establishing that the CNA's actions directly violated established infection control policies and placed the resident at risk for cross-contamination and infection.