Failure to Ensure Nursing Staff Competency in Infection Control During Incontinent Care
Penalty
Summary
The facility failed to ensure that nursing staff, specifically student nurse aides (SNAs), possessed the appropriate competencies and skill sets to provide safe and effective care for residents. Observations revealed that four SNAs did not perform proper hand hygiene before, during, or after providing incontinent care to two residents. Additionally, one SNA wiped back to front during perineal care, and clean briefs were handled without changing gloves or performing hand hygiene after contact with soiled materials. These actions were directly observed during care activities, and staff were seen touching residents' clothing, bedding, and personal items without appropriate infection control measures. Interviews with the involved SNAs indicated a lack of understanding regarding the negative outcomes of improper hand hygiene, and one SNA reported not having been taught how to perform perineal care. Documentation of training for three SNAs could not be located, and the DON confirmed that orientation and clinical training were required but could not provide evidence for all staff. Facility policy required that SNAs only perform care for which they had received training, but this was not consistently followed or documented.