Failure to Follow Infection Control Protocol During Perineal Care
Penalty
Summary
A certified nursing assistant (CNA) failed to follow proper infection prevention and control procedures while providing perineal care to a male resident with multiple complex medical conditions, including alcoholic cirrhosis of the liver, acute respiratory failure, chronic kidney disease, hypertension, dependence on renal dialysis, and a history of syncope. The resident had moderately impaired cognition and was care planned for constipation management. During the observed care, the CNA donned gloves without performing hand hygiene, handled clean and soiled items interchangeably with the same pair of gloves, and contaminated a packet of wet wipes by touching it with soiled gloves. The CNA also failed to change gloves between handling dirty and clean items and did not perform hand hygiene after removing gloves or before leaving the resident's room. The facility's policy for perineal care requires hand hygiene before and after glove use, as well as changing gloves and performing hand hygiene after contact with soiled materials and before handling clean items. The CNA stated she had received training on peri care during orientation and believed she was following protocol, but upon review, acknowledged lapses in glove changing and hand hygiene. The Director of Nursing confirmed that the CNA did not adhere to infection control procedures as outlined in facility policy.