Failure to Follow Infection Control Procedures During Personal Care
Penalty
Summary
Certified Nurse Assistants (CNAs) failed to follow proper infection control procedures while providing personal care to two residents. During observations, CNAs did not change gloves or perform hand hygiene between tasks, such as after perineal care and before touching clean body sites or handling personal items. For one resident, CNAs wore the same soiled gloves while assisting with dressing, applying creams, repositioning, and handling a Hoyer lift sling, only removing gloves and sanitizing hands after multiple tasks were completed. In another instance, a CNA wore the same soiled gloves while assisting with perineal care, dressing, repositioning, and handling personal items, only removing gloves and wiping hands with a sanitizing wipe after all tasks were finished. Interviews with facility leadership confirmed that the expectation, according to facility policy and CDC guidelines, is for staff to perform hand hygiene and change gloves after contact with contaminated body sites and before moving to clean tasks or handling resident belongings. Review of facility policy and CDC guidelines further supported the need for hand hygiene before moving from a contaminated to a clean body site, after contact with blood or bodily fluids, and immediately after glove removal. The observed failures to follow these procedures constituted a deficiency in the facility's infection prevention and control program.